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ICD-10-CM N97.1, Female infertility of tubal origin | No Prior Auth

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`N97.1`, Female infertility of tubal origin

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Hysterosalpingogram (HSG) demonstrating proximal tubal occlusion (explicitly required by the stated covered indication: 'demonstrated on hysterosalpingogram').
Clinical documentation supporting infertility due to tubal origin (e.g., diagnosis consistent with ICD-10 N97.1) and that the tubal occlusion is the clinical reason for attempting transcervical balloon tuboplasty.
Documentation of the selected procedure code justification (e.g., use of CPT 58345) tying the service to the covered indication.

Key Coverage Criteria

Transcervical balloon tuboplasty is medically necessary for members with infertility due to a proximal tubal occlusion demonstrated on hysterosalpingogram.
ICD-10 code N97.1 (Female infertility of tubal origin) is listed as a covered diagnosis for this procedure.
CPT 58345 (Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency) is covered if selection criteria are met (i.e., the indication above).

1 Active Policy

AETNA-CPB-0347, Transcervical Balloon Tuboplasty

Related Codes

58345(1 policies)

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