CommercialCoverageHigh impact
Tubal Sterilization (CPB 0657, reviewed 2025-12-08)
Aetna·OB-GYN, General Surgery·Medical Policy
Effective date
Dec 8, 2025
We identified it
Aug 18, 2026
Summary
Aetna's tubal sterilization policy (CPB 0657) clarifies covered and non-covered procedures effective immediately. Hysteroscopic tubal sterilization (Essure micro-insert) and FemBloc remain experimental/non-covered, while traditional methods (Pomeroy technique, Falope ring, Filshie clip, Hulka-Clemens clip, and salpingectomy) are covered. Billing teams must ensure claims use only approved CPT codes and deny claims for experimental devices like Essure (CPT 0567T, HCPCS A4264).
Action Required
Effective immediately (2025-12-08): Billing team must update claims processing rules and billing software to enforce Aetna's tubal sterilization coverage policy. REQUIREMENTS: (1) DENY all claims for CPT 0567T (permanent fallopian tube occlusion with degradable biopolymer) and CPT 58565 (bilateral fallopian tube cannulation with permanent implants) as experimental/non-covered. (2) DENY all claims for HCPCS A4264 (Essure microinsert delivery system) as non-covered. (3) ALLOW claims for CPT 58600, 58605, 58611, 58615, 58661, 58671, 58700, and 74740 when billed with ICD-10 code Z30.2 (encounter for sterilization). (4) DENY claims when ICD-10 codes indicate contraindications: N73.0-N73.9 (pelvic inflammatory disease), O00.00-O9A.53 (pregnancy/childbirth), Q50.6 or Q51 series (congenital malformations), or Z34.00-Z34.93 (pregnancy supervision). (5) DO NOT COVER CPT 58353 (endometrial ablation) when performed at same time as hysteroscopic sterilization. (6) Update encounter forms and billing system rules to reflect covered vs. non-covered codes. Providers must document Z30.2 diagnosis for coverage. Failure to implement will result in claim denials and patient liability disputes.