For the purpose of this policy infertility is defined as a condition (an interruption, cessation, or disorder of body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery. This is evidenced by the failure to achieve a successful pregnancy after twelve (12) months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after six (6) months for women over age 35 years.
Infertility may include:
Infertility for this policy does not include voluntary sterilization or reversal of voluntary sterilization.
Artificial Insemination is a procedure, also known as intrauterine insemination (IUI); or intracervical/intravaginal insemination (ICI), by which sperm is directly deposited into the vagina, cervix or uterus to achieve fertilization and pregnancy.
Assisted Reproductive Technology (ART) includes all treatments or procedures that involve the in vitro (i.e., outside of the living body) handling of both human oocytes (eggs) and sperm, or embryos, for the purpose of establishing a pregnancy. Treatments and procedures include, but are not limited to:
ART does not include artificial insemination in which sperm are placed directly into the vagina, cervix or uterus.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Coverage is subject to the specific terms of the member’s benefit plan.
In Vitro Fertilization (IVF)
IVF may be considered medically necessary when ALL of the following criteria are met:
AND
AND
IVF for any other indication than listed above will be considered not medically necessary.
58974 | S4011 | S4015 | S4016 | S4017 | S4020 | S4021 |
GIFT or ZIFT may be considered medically necessary when ALL of the following criteria are met:
58976 |
S4013 |
S4014 |
ICSI may be considered medically necessary when the individual has diagnosed infertility due to a male factor (e.g., low sperm count, low function of sperm, abnormal morphology of the sperm, obstructive azoospermia, and nonobstructive azoospermia), as defined by values based on the World Health Organization (WHO) semen-analysis criteria values, demonstrated on at least two separate semen analyses.
89280 |
89281 |
Assisted reproductive technology for the purpose of gamete/oocyte cryopreservation may be considered medically necessary when ANY of the following criteria are met:
Assisted reproductive technology for the purpose of gamete/oocyte cryopreservation is considered not medically necessary when the procedure is performed to:
0058T |
89258 |
89259 |
89337 |
89398 |
TET may be considered medically necessary when the member meets the definition of infertility and ALL of the following criteria are met:
TET for any other indication than listed above will be considered not medically necessary.
58976 |
FET may be considered medically necessary when the member meets the definition of infertility and EITHER of the following criteria is met:
58974 |
58976 |
S4018 |
S4037 |
Ovulation induction management (cycle management) involves the medical management of the individual where medication is used to stimulate development of mature follicles within the ovaries.
It may be performed as part of an assisted fertilization program or as a treatment for infertility outside of an assisted fertilization program.
Ovulation induction management performed without a face-to-face individual/physician encounter (e.g., conducted via telephone) may be considered an eligible
service.
When performed for treatment of infertility, global payment for non-face-to-face ovulation induction management is limited to twelve times (12 cycles) within a twelve (12) month period.
When assisted fertilization is successful, coverage is available for managing the pregnancy and delivery.
Ovulation induction management for any other indication than listed above will be considered not medically necessary.
S4042 |
Immunologic-based therapies to avoid recurrent spontaneous abortion are considered experimental/investigation and, therefore, non-covered due to the lack of scientific evidence for efficacy and safety.
90283 |
The procedures listed on the Table Attachment, Table A, are assisted fertilization procedures that may be reported as part of an assisted fertilization program.
55870 | 58321 | 58322 | 58323 | 58970 | 58974 | 58976 |
76948 | 84702 | 89250 | 89254 | 89255 | 89257 | 89258 |
89259 | 89260 | 89261 | 89264 | 89268 | 89272 | 89280 |
89281 | 89290 | 89291 | 89337 | S4028 | S4042 |
Refer to Table B, Laboratory Services, in the attachments for the quantity of laboratory services per cycle that may be considered medically necessary.
More than two (2) progesterone measurements may be considered medically necessary for infertile women with irregular and prolonged menstrual cycles.
For infertile women with regular menstrual cycles, a mid-luteal serum progesterone measurement (day 21 of a 28-day cycle) may be considered medically necessary.
For infertile women with irregular menstrual cycles, this test would need to be repeated at the mid-luteal phase and weekly thereafter until the next menstrual cycle starts.
Quantities of laboratory services that exceed the frequency guidelines listed on Table B, Laboratory Services, will be denied as not medically necessary.
76830 |
82670 |
83001 |
83002 |
84144 |
84702 |
The following are non-covered professional services because there is no physician service rendered. Cryopreservation, storage, procurement, and thawing of specimens are generally facility charges which will be processed in accordance with the member’s benefits:
0058T | 89258 | 89259 | 89335 | 89337 | 89342 | 89343 |
89344 | 89346 | 89352 | 89353 | 89354 | 89356 | S4026 |
S4027 | S4030 | S4031 | S4040 |
The following reproductive techniques or services are considered experimental/investigational and, therefore, non-covered due to the lack of scientific evidence
for efficacy and safety.
88182 | 89240 | 89251 | 89253 |
The following related services to reproductive technologies/techniques are considered not medically necessary:
S4025 | S9986 |
The following related services to reproductive technologies/techniques are considered not medically necessary:
S9977 | S9986 |
All medical, surgical, and diagnostic services performed to diagnose and treat infertility aregenerallycovered unless the individual member’s contract contains exclusion with regard to the diagnosis and treatment of infertility.
Once it has been established that the ultimate goal for the infertile patient is assisted reproductive technology (IVF, GIFT, ZIFT, etc.), all subsequent related diagnostic, medical, and surgical services are considered part of the assisted reproductive technology program, and are non-covered when the member does not have an assisted reproductive technology benefit.
Related services, including but not limited to lab work and ultrasound, performed in preparation for or in conjunction with assisted reproductive technology services should be reported withthe appropriate diagnosiscode forIVF, GIFT, ZIFT, etc.in order to distinguish them as services associated with assisted reproductive technology program. Such services are non-covered when the member does not have the benefit for assisted reproductive technology.
When reported, assisted reproductive technology program management should be processed under the appropriate procedure codes for the services rendered. Assisted reproductive technology program management generally includes, but is not limited to such services as:
Report the appropriate diagnosiscodefor IVF, GIFT, ZIFT, etc.in order to distinguish them as services associated with an assisted reproductive program. Such services are non-covered when the member does not have an assisted reproductive technology benefit.
58321 | 58322 | 58974 | 58976 | 76830 | 76856 | 76857 |
Medical services or supplies rendered to a gestational carrier or surrogate may be considered medically necessary if the member has ANY of the following
indications:
Services provided to a surrogate or gestational carrier may be a benefit exclusion.
Refer to Table and Table B for information regarding Laboratory Testing.
U-5 Assisted Fertilization Table Attachments
Table A: Assisted Fertilization Procedures
NOTE: This is not an all-inclusive list. The coverage of these procedures may vary according to group specific benefits.
Procedure Code | Description |
55870 | Electroejaculation |
58321 | Artificial insemination; intracervical (AI) |
58322 | Artificial insemination; intrauterine (AI) |
58323 | Sperm washing for artificial insemination |
58970 | Follicle puncture for oocyte retrieval, any method (e.g., laparoscopy, colposcopy) |
58974 | Embryo transfer, intrauterine (IVF) |
58976 | Gamete, zygote, or embryo intrafallopian transfer, any method (GIFT, ZIFT) |
76948 | Ultrasonic guidance for aspiration of ova |
84702 | Gonadotropin, chorionic; qualitative (i.e., implantation monitoring - HCG assay) |
89250 | Culture of oocyte(s)/embryo(s), less than 4 days |
89253 | Assisted embryo hatching, micro-techniques (any method) |
89254 | Oocyte identification from follicular fluid |
89255 | Preparation of embryo for transfer (any method) |
89257 | Sperm identification from aspiration (other than seminal fluid) |
89258 | Cryopreservation; Embryo(s) |
89259 | Cryopreservation; Sperm |
*89260 | Sperm isolation: simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis |
*89261 | Sperm isolation: complex prep (e.g., per co gradient, albumin gradient) for insemination or diagnosis with semen analysis |
89264 | Sperm identification from testis tissue, fresh or cryopreserved |
89268 | Insemination of oocytes |
89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days |
89280 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes |
89281 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes |
89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); ≤ to 5 embryos |
89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); ≥ 5 embryos |
89337 | Cryopreservation; Mature Oocyte(s) |
S4028 | Microsurgical Epididymal Sperm Aspiration (MESA) |
*S4042 | Ovulation induction/cycle management (interpretation of diagnostic tests/studies, non face-to-face medical management of individual) |
* May also be used in the diagnosis/treatment of infertility outside of an assisted fertilization program. |
Table B: Laboratory Services
Lab or Test (CPT Code) | Natural monitoring | Clomid monitoring | Clomid IUI | Inj Monthly Cycle | Inj IUI | IVF | GIFT | FET | PM |
Transvaginal ultrasound (76830) | 2 | 6 | 6 | 8 | 10 | n/a | n/a | n/a | n/a |
Estradiol (82670) |
2 | 6 | 6 | 8 | 10 | 10 | 10 | 10 | n/a |
FSH (83001) | 2 | 6 | 6 | 8 | 10 | 10 | 10 | 10 | n/a |
LH (83002) | 2 | 6 | 6 | 8 | 10 | 10 | 10 | 10 | n/a |
Progesterone (84144) | 2* | 2* | 2* | 8 | 10 | 10 | 10 | 10 | 3 |
hCG (84702) | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 3 |
Key:
IUI: intra-uterine insemination FET: frozen embryo transfer
Inj: injection PM: pregnancy monitoring
IVF: in-vitro fertilization FSH: follicle stimulating hormone
GIFT: gamete intra-fallopian transfer LH: luteinizing hormone
hCG: human chorionic gonadotropin
*Note:
More than 2 progesterone measurements may be considered for infertile women with irregular and prolonged menstrual cycles.
For infertile women with regular menstrual cycles, a mid-luteal serum measurement (day 21 of a 28-day cycle) may be considered medically necessary.
For infertile women with irregular menstrual cycles, this test would need to be repeated at the mid-luteal phase and weekly thereafter until the next menstrual cycle starts.
N46.01 | N46.021 | N46.022 | N46.023 | N46.024 | N46.025 | N46.029 |
N46.11 | N46.121 | N46.122 | N46.123 | N46.124 | N46.125 | N46.129 |
N46.8 | N46.9 | N97.0 | N97.1 | N97.2 | N97.8 | N97.9 |
Z31.7 | Z31.81 | Z31.83 | Z31.9 |
Z31.0 |
NA
Internal Medical Policy Committee 1-22-2020 Coding update
Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.