Transcervical Balloon Tuboplasty

Transcervical balloon tuboplasty (CPT 58345; ICD‑10 N97.1) is covered when performed for infertility due to a proximal fallopian tube occlusion documented on hysterosalpingogram. It is considered experimental/investigational and not covered for distal tubal occlusion or any other indications, and related CPT/HCPCS codes are only covered if the documented proximal‑occlusion selection criteria are met.

"Transcervical balloon tuboplasty is medically necessary for members with infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram."

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