Aetna modified CPB 0657 for tubal sterilization, effective December 9, 2025. Here's what changes for billing teams.
Aetna, a CVS Health company, updated its tubal sterilization coverage policy under CPB 0657 in Aetna's system to clarify which procedures meet medical necessity and which remain experimental. The policy covers CPT codes 58600, 58605, 58615, 58661, 58671, and 58700 for approved sterilization methods — while explicitly excluding CPT 58565 and Category III code 0567T as not covered. If your team bills any of these codes for Aetna members, review your claim workflows now.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Tubal Sterilization — CPB 0657 |
| Policy Code | CPB 0657 |
| Change Type | Modified |
| Effective Date | December 9, 2025 |
| Impact Level | Medium |
| Specialties Affected | OB/GYN, Minimally Invasive Gynecologic Surgery, Women's Health |
| Key Action | Remove CPT 58565 and HCPCS A4264 from your covered-service charge capture for Aetna and add CPT 58700 (total salpingectomy) to your covered list |
Aetna Tubal Sterilization Coverage Criteria and Medical Necessity Requirements 2025
The Aetna tubal sterilization coverage policy under CPB 0657 defines medical necessity around method — not just intent. Aetna covers five specific approaches. If your documentation doesn't map to one of them, expect a claim denial.
The five covered methods are:
| # | Covered Indication |
|---|---|
| 1 | Falope ring — billed under CPT 58615 or 58671 |
| 2 | Filshie clip (titanium clip) — billed under CPT 58615 or 58671 |
| 3 | Hulka-Clemens clip — billed under CPT 58615 or 58671 |
| 4 | Partial salpingectomy (Pomeroy or Parkland technique) — billed under CPT 58600, 58605, or add-on code +58611 at time of cesarean |
| 5 | Total salpingectomy (bilateral or complete salpingectomy) — billed under CPT 58700 or 58661 |
Total salpingectomy is on this covered list. That matters. The shift toward opportunistic salpingectomy for ovarian cancer risk reduction has driven higher volume of CPT 58700 and 58661 claims. Aetna's explicit inclusion of total salpingectomy in the medical necessity criteria is a billing team's green light — provided documentation supports sterilization intent and the correct diagnosis codes accompany the claim.
The diagnosis code you'll use most often is Z30.2 (Encounter for sterilization). For postpartum cases, the relevant ICD-10 codes fall in the O00.00–O9A.53 pregnancy and puerperium range. Match your diagnosis to the clinical context. A postpartum bilateral salpingectomy billed with Z30.2 and CPT 58700 reads clearly to Aetna's system. Missing or mismatched diagnosis codes are a common source of denial here.
The policy doesn't explicitly mention prior authorization requirements within the CPB 0657 document itself. That doesn't mean prior auth isn't required on your specific plan contracts. Always verify prior authorization requirements at the plan level before scheduling elective sterilization procedures for Aetna members. A covered procedure without a required prior auth is still a denial.
Aetna Tubal Sterilization Exclusions and Non-Covered Indications
This is where billing teams get hurt. The policy lists two categories as experimental, investigational, or unproven — and explicitly states that safety and long-term effects haven't been established.
Hysteroscopic tubal sterilization (also called transcervical sterilization) is not covered. This includes the Essure Micro-Insert system, billed via CPT 58565 and HCPCS A4264. If anyone on your team is still billing CPT 58565 for Aetna, stop immediately. The Essure device has been off the U.S. market since 2019, but the code and claim pattern still appear in some older charge capture templates. Flag it.
FemBloc permanent contraceptive system is also not covered. FemBloc uses a degradable biopolymer implant delivered transcervically — billed under Category III code 0567T. Aetna considers this experimental. Don't bill 0567T for Aetna members expecting reimbursement.
There's also a note on the Adiana Permanent Contraception System: the manufacturer, Hologic, has discontinued it. The policy flags this for historical reference. You won't see active Adiana claims, but older accounts receivable reviews might surface it.
The pattern here is consistent: anything transcervical or hysteroscopic for permanent contraception is out. All covered methods are surgical — laparoscopic, abdominal, or vaginal.
Coverage Indications at a Glance
| Indication / Method | Status | Relevant CPT/HCPCS Codes | Notes |
|---|---|---|---|
| Falope ring | Covered | 58615, 58671 | Medical necessity criteria must be met |
| Filshie clip (titanium clip) | Covered | 58615, 58671 | Medical necessity criteria must be met |
| Hulka-Clemens clip | Covered | 58615, 58671 | Medical necessity criteria must be met |
| Partial salpingectomy (Pomeroy/Parkland) | Covered | 58600, 58605, +58611 | +58611 is add-on at time of cesarean only |
| Total salpingectomy (bilateral/complete) | Covered | 58700, 58661 | Increasingly common; explicitly covered |
| Hysteroscopic / transcervical sterilization (Essure) | Not Covered | 58565, A4264 | Experimental/investigational; Essure off market since 2019 |
| FemBloc permanent contraceptive system | Not Covered | 0567T | Experimental/investigational |
| Adiana Permanent Contraception System | Not Covered | N/A | Manufacturer (Hologic) discontinued production |
| Hysterosalpingography post-hysteroscopic procedure | Covered if criteria met | 74740 | Used for confirmation 3 months post-procedure (historical use) |
| Saline infusion sonohysterography | Covered if criteria met | 58340 | Coverage dependent on clinical context |
Aetna Tubal Sterilization Billing Guidelines and Action Items 2025
The effective date is December 9, 2025. Here's what your billing and coding team should do now.
| # | Action Item |
|---|---|
| 1 | Audit your charge capture templates for CPT 58565 and HCPCS A4264. If these appear as active billable codes for Aetna, remove them. They're not covered under CPB 0657. A single claim for 58565 on an Aetna member generates a denial and potentially flags the account for review. |
| 2 | Confirm CPT 58700 is mapped correctly in your system as a covered service. Total salpingectomy billing under Aetna is explicitly supported by this policy. If your team has been treating it as a gray area, it isn't — document the sterilization intent clearly in the operative note and pair it with Z30.2 or the appropriate pregnancy ICD-10 code. |
| 3 | Remove 0567T from your Aetna fee schedule workflows. Aetna won't reimburse this Category III code for the FemBloc system. If your providers are performing or planning FemBloc procedures, counsel them on the reimbursement gap before scheduling. |
| 4 | Verify prior authorization requirements at the plan level before the procedure date. CPB 0657 doesn't spell out prior auth requirements, but individual Aetna plan contracts may require it for elective sterilization. Call Aetna provider services or check the provider portal for your specific plan codes. A claim without required prior auth is a denial regardless of medical necessity. |
| 5 | Check add-on code +58611 usage. This code covers ligation or transection of the fallopian tube at the time of cesarean delivery or intra-abdominal surgery. It can only be billed as an add-on — not a standalone. Confirm your billing system enforces that rule and that the primary procedure code is always present. |
| 6 | Review postpartum sterilization claims for correct diagnosis pairing. Postpartum tubal sterilization billed under CPT 58605 needs a diagnosis code from the pregnancy/puerperium range (O00.00–O9A.53). Using Z30.2 alone on a postpartum claim may trigger an edit. Talk to your compliance officer if you're seeing inconsistent denials on postpartum cases — this is a common failure point. |
| 7 | Don't bill CPT 74740 for routine sterilization follow-up. This hysterosalpingography code applies in the context of post-hysteroscopic sterilization confirmation — historically used after Essure placement. Since hysteroscopic sterilization is now excluded, 74740 has very narrow remaining use under this policy. If your team is billing it, document the specific clinical context carefully. |
| 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 Tubal Sterilization Under CPB 0657
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 58340 | CPT | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography |
| 58600 | CPT | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral |
| 58605 | CPT | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral |
| +58611 | CPT | Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (add-on) |
| 58615 | CPT | Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring), vaginal or suprapubic approach |
| 58661 | CPT | Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) |
| 58671 | CPT | Laparoscopy, surgical; with lysis of adhesions with occlusion of oviducts by device (e.g., band, clip, or Falope ring) |
| 58700 | CPT | Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) |
| 74740 | CPT | Hysterosalpingography, radiological supervision and interpretation (three months after hysteroscopic sterilization) |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0567T | CPT (Cat. III) | Permanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach | Experimental/investigational — FemBloc system |
| 58565 | CPT | Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants | Not covered — hysteroscopic/transcervical sterilization |
| A4264 | HCPCS | Permanent implantable contraceptive intratubal occlusion device(s) and delivery system (Essure micro-insert) | Not covered — Essure off U.S. market since 2019 |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| Z30.2 | Encounter for sterilization |
| O00.00–O9A.53 | Pregnancy, childbirth and the puerperium (range) |
| N70.11 | Chronic salpingitis and oophoritis (hydrosalpinx) |
| N70.12 | Chronic salpingitis and oophoritis (hydrosalpinx) |
| N70.13 | Chronic salpingitis and oophoritis (hydrosalpinx) |
| N73.0 | Parametritis and pelvic cellulitis |
| N73.1 | Parametritis and pelvic cellulitis |
| N73.2 | Parametritis and pelvic cellulitis |
| N73.3 | Female pelvic peritonitis |
| N73.4 | Female pelvic peritonitis |
| N73.5 | Female pelvic peritonitis |
| N73.8 | Other and unspecified female pelvic inflammatory diseases |
| N73.9 | Other and unspecified female pelvic inflammatory diseases |
| N97.0–N97.9 | Female infertility (patient undergoing in vitro fertilization cycle) |
| E23.0 | Hypopituitarism (patient undergoing IVF cycle) |
| Q50.6 | Other congenital malformations of fallopian tube and broad ligament |
| Q51.0 | Congenital malformations of uterus |
| Q51.21–Q51.4, Q51.810–Q51.818 | Congenital malformations of uterus |
| Q51.9 | Congenital malformations of uterus |
| Z31.83 | Encounter for assisted reproductive fertility procedure cycle (IVF) |
| Z34.0–Z34.4x | Encounter for supervision of normal pregnancy (multiple subcodes) |
The ICD-10 list in CPB 0657 runs 125 codes. The full set covers the pregnancy and puerperium range (O codes), female pelvic inflammatory conditions, infertility diagnoses tied to IVF cycles, and congenital uterine malformations. If your clinical scenarios include hydrosalpinx management alongside sterilization, confirm your diagnosis pairing with your compliance officer before billing. Hydrosalpinx cases that lead to salpingectomy involve a different clinical rationale than elective sterilization — and that distinction matters for claim review.
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