Aetna modified CPB 0347 for transcervical balloon tuboplasty, effective September 26, 2025. Here's what billing teams need to know.
Aetna, a CVS Health company, updated its transcervical balloon tuboplasty coverage policy under CPB 0347 in the Aetna system. The core medical necessity standard remains: the procedure is covered for members with infertility caused by proximal tubal occlusion confirmed on hysterosalpingogram. The primary billable code is CPT 58345, with supporting codes 58340, 74740, 74742, and 76831 all relevant to how you build out the claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Transcervical Balloon Tuboplasty |
| Policy Code | CPB 0347 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | Medium |
| Specialties Affected | Reproductive endocrinology, OB/GYN, interventional radiology |
| Key Action | Confirm ICD-10 N97.1 is on all claims for CPT 58345 and that hysterosalpingogram results are in the record before billing |
Aetna Transcervical Balloon Tuboplasty Coverage Criteria and Medical Necessity Requirements 2025
Aetna's coverage policy for transcervical balloon tuboplasty is narrow by design. The procedure is medically necessary for one specific patient presentation: female infertility due to proximal tubal occlusion, confirmed by hysterosalpingogram (HSG).
That's the whole gate. No HSG documentation in the record means no coverage, full stop. Before you bill CPT 58345, your team needs to confirm the imaging report is in the chart and that it specifically identifies proximal tubal occlusion — not just any tubal abnormality.
ICD-10-CM N97.1 (Female infertility of tubal origin) is the diagnosis code that maps to this indication. Every claim for CPT 58345 should carry N97.1. If your billing team is using a broader infertility code, a claim denial is the likely result.
The coverage policy doesn't explicitly list prior authorization requirements in this version of CPB 0347. That said, infertility procedures at Aetna frequently require prior auth at the plan level — especially when tied to a broader infertility benefit. Check the member's specific plan before assuming prior authorization isn't needed. Call Aetna's provider line or pull the plan documents if you're not sure.
Reimbursement for transcervical balloon tuboplasty billing is also plan-dependent. Some Aetna plans exclude infertility treatment entirely. If the member's plan has an infertility exclusion, CPT 58345 won't get paid regardless of the medical necessity criteria in CPB 0347. Verify benefits before the procedure, not after.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Infertility due to proximal tubal occlusion confirmed by hysterosalpingogram | Covered | CPT 58345, ICD-10 N97.1 | HSG documentation required; confirm plan-level infertility benefit |
Aetna Transcervical Balloon Tuboplasty Billing Guidelines and Action Items 2025
This is a focused policy with a tight set of covered indications. Your action items are equally focused.
| # | Action Item |
|---|---|
| 1 | Audit your charge capture for CPT 58345 before billing any claims with a date of service on or after September 26, 2025. The modified policy is now in effect. Make sure your charge capture reflects the current medical necessity criteria — proximal tubal occlusion confirmed by HSG — not prior interpretations of the policy. |
| 2 | Confirm ICD-10-CM N97.1 is attached to every CPT 58345 claim. Female infertility of tubal origin is the correct diagnosis code for this procedure under CPB 0347. Broader infertility codes won't align with Aetna's criteria and will likely trigger a claim denial. |
| 3 | Verify the hysterosalpingogram report is documented before you bill. Aetna's medical necessity standard requires the proximal occlusion to be demonstrated on HSG. That means a radiologist or treating physician report confirming the finding — not just a clinical note saying the patient had imaging. CPT 74740 (hysterosalpingography, radiological supervision and interpretation) is the related code for that service. |
| 4 | Check plan-level infertility benefits before the procedure. CPB 0347 sets the medical necessity standard. It doesn't override plan exclusions. If the member's plan excludes infertility treatment, you're billing into a wall. Run a benefits check for the specific Aetna plan — not just Aetna generically. |
| 5 | Review prior authorization requirements at the plan level. CPB 0347 doesn't spell out a prior auth mandate, but many Aetna commercial plans require prior authorization for infertility procedures. If your practice doesn't have a standing workflow for checking this, build one. A missing prior auth is a clean path to denial — and retro-authorization for infertility procedures is rarely granted. |
| 6 | Update your procedure-to-diagnosis crosswalk for transcervical balloon tuboplasty billing. If your practice uses an internal charge capture tool or superbill, make sure CPT 58345 links to N97.1 as the primary ICD-10. This catches coding errors before claims leave your system. |
If your patient mix includes a high volume of infertility procedures and you're uncertain how this coverage policy revision interacts with your payer mix, loop in your compliance officer or billing consultant before the next billing cycle.
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Transcervical Balloon Tuboplasty Under CPB 0347
Covered CPT Codes (When Selection Criteria Are Met)
These codes are covered when Aetna's medical necessity criteria are satisfied — specifically, female infertility with proximal tubal occlusion confirmed on hysterosalpingogram.
| Code | Type | Description |
|---|---|---|
| 58345 | CPT | Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency |
Other CPT Codes Related to CPB 0347
These codes appear in the policy as related services. They support the diagnostic workup and procedural documentation for transcervical balloon tuboplasty billing. They are not listed as covered under the same selection criteria as CPT 58345 — they are supporting or diagnostic codes relevant to the clinical pathway.
| Code | Type | Description |
|---|---|---|
| 58340 | CPT | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography |
| 74740 | CPT | Hysterosalpingography, radiological supervision and interpretation |
| 74742 | CPT | Transcervical catheterization of fallopian tube, radiological supervision and interpretation |
| 76831 | CPT | Saline infusion sonohysterography (SIS), including color flow Doppler, when performed |
CPT 74740 is the code that ties directly to the HSG requirement in the medical necessity criteria. If your team is billing the diagnostic imaging separately, this is the right code. CPT 76831 (saline infusion sonohysterography) and 58340 (SIS catheterization) come into play if the workup includes SIS rather than or in addition to HSG.
CPT 74742 covers radiological supervision and interpretation for transcervical fallopian tube catheterization — relevant when interventional radiology is involved in the procedure itself.
Other HCPCS Codes Related to CPB 0347
| Code | Type | Description |
|---|---|---|
| A9574 | HCPCS | Air polymer-type A intrauterine foam, 0.1 ml |
HCPCS A9574 appears in the policy as a related code. This covers the contrast or foam agent used in some uterine imaging procedures. If your practice uses this product as part of the diagnostic workup, code it separately — but confirm coverage with the specific Aetna plan before assuming it's billable alongside CPT 58345.
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| N97.1 | Female infertility of tubal origin |
N97.1 is the only ICD-10 code listed in CPB 0347. It is the required diagnosis for medical necessity under this coverage policy. Don't append a broader infertility code and expect the claim to process cleanly — Aetna's criteria are specific to tubal-origin infertility.
Get the Full Picture for CPT 58345
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.