| Effective Date:08/05/2004 |
Title:Trans-Cervical Balloon Tubuloplasty
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| Revision Date:12/01/2016
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Document:BI061:00
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| CPT Code(s):58345
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
Trans-Cervical Balloon Tubuloplasty (TBT)
is a procedure which dilates the fallopian tubes. It is a procedure for
treating infertility and therefore not a covered benefit. See policy BI057 on
Infertility Diagnosis and Treatment (which details the coverage of limited
diagnostic tests and exclusion of treatment).
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Medical Statement
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Trans-Cervical Balloon Tubuloplasty (TBT) is a procedure used to dilate the
fallopian tubes when fallopian tube obstruction/occlusion has been identified as
a possible cause of infertility. Procedures to treat infertility are not a
covered benefit.
Codes
Used In This BI:
58345 Re-open Fallopian Tube
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Limits
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Intentially left empty
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Reference
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Intentially left empty
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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