Coverage Policy Manual
Policy #: 2014008
Category: Medicine
Initiated: April 2014
Last Review: April 2023
  Infertility Services
Description:
This policy addresses Infertility Diagnostic Testing, Intrauterine Insemination and Assisted Reproductive Technology also referred to as In-Vitro Fertilization.
 
 
Related Policies:
 
2005021- Preimplantation Genetic Diagnosis, Testing or Treatment
 
Policy/
Coverage:
Effective February 2024
 
Coverage eligibility of Assisted Reproductive Technology AND Infertility services is a contract-specific benefit issue. Furthermore, this policy only applies to services performed on the covered member. No infertility related services are eligible for benefits when:  (1) the Covered Person or the Covered Person’s Spouse has undergone a voluntary sterilization at any point in their medical history, (2) the infertility is the result of natural age-related hormone reduction (i.e., postmenopausal or 45 years of age or older), (3) when a surrogate is used or (4) when the covered person has had three live births by any means.
  
Where benefits are available, coverage is allowed for in vitro fertilization provided by an In-Network Provider. Coverage for in vitro fertilization is limited to up to four completed oocyte retrievals per lifetime of the member or two live births from separate pregnancies as a result of the in vitro fertilization. After a first live birth is achieved as a result of a successful in vitro fertilization cycle, up to two additional completed oocyte retrievals may be covered.
 
Note: All viable embryos, fresh or frozen, must be used before undergoing an additional oocyte retrieval.
 
For the purposes of this policy, the definition of Infertility isas follows:
 
A covered person and his or her spouse are unable to conceive after at least one (1) year of regular unprotected vaginal sexual intercourse, when the wife is less than 36 year of age, or at least six (6) months of regular unprotected vaginal sexual intercourse when the wife is 36 years of age or older; or a covered person has a medically documented inability to conceive due to at least one of the following:
 
1. Stage 4 surgically treated endometriosis; OR
2. Exposure in utero to diethylstilbestrol, commonly known as DES; OR
3. Blockage or removal of one or both fallopian tubes, not as a result of voluntary sterilization; OR
4. Untreatable, abnormal male factors contributing to infertility, not as a result of voluntary sterilization (untreatable retrograde ejaculation, untreatable penectomy, refractory erectile dysfunction; spouse’s biologic status precludes viable sperm availability); OR
5. Cervical factor infertility; OR
6. Vaginismus preventing intercourse; OR
7. Anovulatory females who have failed to conceive after a 6-month trial of ovulation induction with timed intercourse under the supervision and monitoring of a physician; OR
8. Absence or abnormality of uterus that precludes conception with evidence of intact ovarian function; OR
9. Spouse’s biologic status precludes viable sperm availability.
 
*The Infertility Services addressed in this policy are divided into three separate sections: Infertility Diagnostic Testing, Artificial Insemination and Assisted Reproductive Technology (In-Vitro Fertilization)
 
I. INFERTILITY DIAGNOSTIC TESTING
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
The following diagnostic testing for infertility meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness when:
 
1. The member and the member’s spouse who is of reproductive age and has not conceived after one (1) year of unprotected vaginal sexual intercourse, in the absence of documentation of a known, diagnosed, cause of his or her infertility.
 
OR
 
2. The member or member’s spouse is a woman aged 36 years of age or over with no known clinical cause of infertility or history of predisposing factors for infertility who has not conceived after 6 months of unprotected vaginal sexual intercourse.
 
Diagnostic Testing:
 
1. Verification of ovulation
a. Serum progesterone timed 7 days prior to expected menses
b. Urine LH monitoring
2. Ovarian reserve testing
a. Cycle day 3 FSH, estradiol
b. Antral follicle count on cycle day 3
c. Antimüllerian hormone (AMH)
3. Transvaginal ultrasound of the uterus and ovaries.
4. Hysterosalpingography (HSG) or saline infusion sonography (SIS) for the evaluation of fallopian tube and uterine cavity in women who are not known  to have comorbidities such as pelvic inflammatory disease, previous ectopic  pregnancy or endometriosis.
5. Laparoscopy in women who are thought to have comorbidities to assess tubal and other pelvic pathology.
6. Endometrial biopsy, only in women with suspected uterine pathology such as hyperplasia.
7. Semen analysis- should include analysis performed on two separate occasions, with each specimen obtained after 2-5 days of abstinence.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Diagnostic testing for infertility does not meet member benefit certificate primary coverage that there be scientific evidence of effectiveness when any of the following apply:
 
1. Infertility resulting from voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. One of the covered persons has had three live births by any means.
 
For members with contracts without primary coverage criteria, diagnostic testing for infertility is considered not medically necessary when any of the following apply:
 
1. Infertility as a result of voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR.
4. One of the covered persons has had three live births by any means.
 
The following diagnostic testing for infertility does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and are therefore, not eligible for benefits:
 
1. Post-coital testing of cervical mucus;
2. Screening for antisperm antibodies;
3. Hamster testing or Sperm Penetration Assay;
4. Sperm DNA integrity testing (Sperm Chromatin Structure Assay [SCSA], Comet Assay, Sperm DNA fragmentation assay, TUNEL assay) (Effective 10/ 2016);
5. Gene expression profiling for endometrial receptivity analysis (Effective 07/2021).
  
For members with contracts without member benefit certificate primary coverage criteria, the following diagnostic testing for infertility is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
1. Post-coital testing of cervical mucus;
2. Screening for antisperm antibodies;
3. Hamster testing or Sperm Penetration Assay;
4. Sperm DNA integrity testing (Sperm Chromatin Structure Assay [SCSA], Comet Assay, Sperm   DNA fragmentation assay, TUNEL assay) (Effective 10/ 2016);
5. Gene expression profiling for endometrial receptivity analysis (Effective 07/2021).
 
 
II. ARTIFICIAL INSEMINATION
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Up to 6 cycles* of intrauterine or intracervical insemination meets member benefit certificate primary coverage criteria when the member or member’s spouse has a medically documented inability to conceive due to at least one of the following:
 
1. Surgically treated endometriosis; OR
2. Fallopian tube blockage or removal, not as a result of voluntary sterilization, with documentation of patency of one fallopian tube; OR
3. Untreatable, abnormal male factors contributing to infertility, not as a result of voluntary sterilization (untreatable retrograde ejaculation, untreatable penectomy, refractory erectile dysfunction; spouse’s biologic status precludes viable sperm availability); OR
4. Evidence of discordance for sexually transmitted disease carriage (e.g., human immunodeficiency disease carriage, hepatitis B or C); OR
5. Cervical factor infertility; OR
6. Vaginismus preventing intercourse; OR
7. Anovulatory females who have failed to conceive after a 6-month trial of ovulation induction with timed intercourse under the supervision and monitoring of a physician; OR
8. Unexplained infertility in the member or member’s spouse after at least 1 year of regular unprotected vaginal sexual intercourse. (Note: Unexplained infertility is defined as no detected abnormalities identified from standard infertility diagnostic testing); OR
9. Spouse’s biologic status precludes viable sperm availability.
 
NOTE: Contraindications include active cervical, uterine, or pelvic infection; absence of uterus; bilateral fallopian tube obstruction or absence; bilateral absence of ovaries; or other known causes of complete anovulation.
 
If conception does not occur after the initial 6 cycles* of intrauterine or intracervical insemination, up to 6 additional cycles may be eligible for benefits.
 
Does Not Meet Primary Coverage Criteria Or Is Not Medically Necessary For Contracts Without Primary Coverage Criteria
 
Intrauterine or intracervical insemination for indications other than those listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness, including, but not limited to, the following:
 
1. Infertility as a result of voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. One of the covered persons has had three live births by any means; OR
5. Presence of any one of the following contraindications: active cervical, uterine, or pelvic infection; absence of uterus; bilateral fallopian tube obstruction or absence; bilateral absence of ovaries; or other known causes of complete anovulation.
 
For members with contracts without primary coverage criteria, intrauterine or intracervical insemination for indications other than those listed above as covered is considered not medically necessary:
 
1. Infertility as a result of voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. One of the covered persons has had three live births by any means; OR
5. Presence of any one of the following contraindications: active cervical, uterine, or pelvic infection; absence of uterus; bilateral fallopian tube obstruction or absence; bilateral absence of ovaries; or other known causes of complete anovulation.
 
 
III. ASSISTED REPRODUCTIVE TECHNOLOGY (IN-VITRO FERTILIZATION)
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Assisted Reproductive Technology (In Vitro Fertilization) meets member benefit certificate primary coverage criteria and is covered provided other less invasive therapies, where appropriate, have failed (e.g., intrauterine insemination):
 
1. When the member and the member’s spouse have a history of unexplained infertility of at least two years duration;
 
OR
 
2. The member or the member’s spouse has infertility associated with one or more of the following medical conditions:
a. Stage 4 surgically treated endometriosis; OR
b. Exposure in utero to diethylstilbestrol, commonly known as DES; OR
c. Blockage or removal of one or both fallopian tubes, not as a result of voluntary sterilization; OR
d. Untreatable, abnormal male factors contributing to infertility not as a result of voluntary sterilization  (e.g., untreatable retrograde ejaculation, untreatable penectomy, refractory erectile dysfunction; spouse’s biologic status precludes viable sperm availability) and Member has failed to conceive after 6 trials of artificial insemination; OR
e. Cervical factor infertility; OR
f. Vaginismus preventing intercourse; OR
g. Anovulatory females who have failed to conceive after a 6-month trial of ovulation induction with timed intercourse under the supervision and monitoring of a physician; OR
h. Absence or abnormality of uterus that precludes conception with evidence of intact ovarian function; OR
i. Member has failed to conceive after 6 trials of artificial insemination; OR
j. Spouse’s biologic status precludes viable sperm availability.
 
AND
 
3. The in vitro fertilization procedures are performed by a physician who is board certified in reproductive endocrinology and infertility. NOTE: Related procedures (e.g., lab tests, ultrasounds) may be performed by a provider in consultation with the board certified or the IVF experienced physician.
 
*Preimplantation Genetic Diagnosis, Testing and Treatment is addressed in policy #2005021
 
Does Not Meet Primary Coverage Criteria Or Is Not Medically Necessary For Contracts Without Primary Coverage Criteria
 
Assisted Reproductive Technology (In Vitro Fertilization) does not meet member benefit certificate primary coverage criteria when either the member or the member’s spouse has:
 
1. Infertility as a result of a voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. When one of the covered persons has had three live births by any means.
 
For members with contracts without primary coverage criteria Assisted Reproductive Technology (In Vitro Fertilization) is considered not medically necessary when either the member or the member’s spouse has:
 
1. Infertility as a result of a voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. When one of the covered persons has had three live births by any means.
 
The following Assisted Reproductive Technology techniques do not meet member benefit certificate primary coverage criteria of effectiveness or are considered not medically necessary for members with contracts without primary coverage criteria:
 
1. Assisted hatching (CPT code 89253);
2. Co-culture of embryos (CPT code 89251);
3. Cryopreservation of ovarian tissue or oocytes( CPT code 89240, 0058T, 0357T, 89337);
4. Cryopreservation of testicular tissue in prepubertal boys(CPT code 89335);
5. Storage and thawing of ovarian tissue, oocytes, or testicular tissue (CPT codes 89344, 89346, 89354 and 89356)
 
Effective July 2021 through January 2024
 
Coverage eligibility of Assisted Reproductive Technology AND Infertility services is a contract-specific benefit issue. Furthermore, this policy only applies to services performed on the covered member. No infertility related services are eligible for benefits when:  (1) the Covered Person or the Covered Person’s Spouse has undergone a voluntary sterilization at any point in their medical history, (2) the infertility is the result of natural age-related hormone reduction (i.e., postmenopausal or 45 years of age or older), (3) when a surrogate is used or (4) when the covered person has had three live births by any means.
  
Where benefits are available, coverage is allowed for in vitro fertilization provided by an In-Network Provider. Coverage for in vitro fertilization is limited to up to four completed oocyte retrievals per lifetime of the member or two live births from separate pregnancies as a result of the in vitro fertilization. After a first live birth is achieved as a result of a successful in vitro fertilization cycle, up to two additional completed oocyte retrievals may be covered.
 
Note: All viable embryos, fresh or frozen, must be used before undergoing an additional oocyte retrieval.
  
For the purposes of this policy, the definition of Infertility is as follows:
 
A covered person and his or her spouse are unable to conceive after at least one (1) year of regular unprotected vaginal sexual intercourse, when the wife is less than 36 year of age, OR at least six (6) months of regular unprotected vaginal sexual intercourse when the wife is 36 years of age or older; OR a covered person has a medically documented inability to conceive due to at least one of the following:
 
1. Stage 4 surgically treated endometriosis;
2. Exposure in utero to diethylstilbestrol, commonly known as DES;
3. Blockage or removal of one or both fallopian tubes, not as a result of voluntary sterilization
4. Untreatable, abnormal male factors contributing to infertility, not as a result of voluntary sterilization (untreatable retrograde ejaculation, untreatable penectomy, refractory erectile dysfunction);
5. Cervical factor infertility;
6. Vaginismus preventing intercourse;
7. Anovulatory females who have failed to conceive after a 6 month trial of ovulation induction with timed intercourse under the supervision and monitoring of a physician; or
8. Absence or abnormality of uterus that precludes conception with evidence of intact ovarian function
 
*The Infertility Services addressed in this policy are divided into three separate sections: Infertility Diagnostic Testing, Artificial Insemination and Assisted Reproductive Technology (In-Vitro Fertilization)
 
I. INFERTILITY DIAGNOSTIC TESTING
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
The following diagnostic testing for infertility meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness when:
 
    •  the member and the member’s spouse who is of reproductive age and has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of documentation of a known, diagnosed, cause of his or her infertility.  
 
 OR
 
    • The member or member’s spouse is a women aged 36 years of age or over with no known clinical cause of infertility or history of predisposing factors for infertility who has not conceived after 6 months of unprotected vaginal sexual intercourse.
 
Diagnostic Testing:
  
1. Verification of ovulation
    • Serum progesterone timed 7 days prior to expected menses
    • Urine LH monitoring
 2. Ovarian reserve testing
    • Cycle day 3 FSH, estradiol
    • Antral follicle count on cycle day 3
    • Antimüllerian hormone (AMH)
3. Transvaginal ultrasound of the uterus and ovaries.
4. Hysterosalpingography (HSG) or saline infusion sonography (SIS) for the evaluation of fallopian tube and uterine cavity in women who are not known  to have comorbidities such as pelvic inflammatory disease, previous ectopic  pregnancy or endometriosis.
5. Laparoscopy in women who are thought to have comorbidities to assess tubal and other pelvic pathology.
6. Endometrial biopsy, only in women with suspected uterine pathology such as hyperplasia.
7. Semen analysis- should include analysis performed on two separate occasions, with each specimen obtained after 2-5 days of abstinence.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Diagnostic testing for infertility does not meet member benefit certificate primary coverage that there be scientific evidence of effectiveness when any of the following apply:
 
1. Infertility resulting from voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. One of the covered persons has had three live births by any means.
 
For members with contracts without primary coverage criteria, diagnostic testing for infertility is considered not medically necessary when any of the following apply:
 
1. Infertility as a result of voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used.
4. One of the covered persons has had three live births by any means.
 
The following diagnostic testing for infertility does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and are therefore, not eligible for benefits:
  
1. Post-coital testing of cervical mucus
2. Screening for antisperm antibodies
3. Hamster testing or Sperm Penetration Assay
4. Sperm DNA integrity testing (Sperm Chromatin Structure Assay [SCSA], Comet Assay, Sperm DNA fragmentation assay, TUNEL assay). (Effective 10/ 2016)
5. Gene expression profiling for endometrial receptivity analysis (Effective 07/2021)
  
For members with contracts without member benefit certificate primary coverage criteria, the following diagnostic testing for infertility is considered investigational.  Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
1. Post-coital testing of cervical mucus
2. Screening for antisperm antibodies
3. Hamster testing or Sperm Penetration Assay
4. Sperm DNA integrity testing (Sperm Chromatin Structure Assay [SCSA], Comet Assay, Sperm   DNA fragmentation assay, TUNEL assay). (Effective 10/ 2016)
5. Gene expression profiling for endometrial receptivity analysis (Effective 07/2021)
 
 
II. ARTIFICIAL INSEMINATION
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
  
Up to 6 cycles* of intrauterine or intracervical insemination meets member benefit certificate primary coverage criteria when the member or member’s spouse has a medically documented inability to conceive due to at least one of the following:
  
1. Surgically treated endometriosis, or
2. Fallopian tube blockage or removal, not as a result of voluntary sterilization, with documentation of patency of one fallopian tube; or
3. Untreatable, abnormal male factors contributing to infertility, not as a result of voluntary sterilization (untreatable retrograde ejaculation, untreatable penectomy, refractory erectile dysfunction); or
4. Evidence of discordance for sexually transmitted disease carriage (e.g., human immunodeficiency disease carriage, hepatitis B or C);
5. Cervical factor infertility; or
6. Vaginismus preventing intercourse; or
7. Anovulatory females who have failed to conceive after a 6 month trial of ovulation induction with timed intercourse under the supervision and monitoring of a physician; or
8. Unexplained infertility in the member or member’s spouse after at least 1 year of regular unprotected vaginal sexual intercourse. (Note: Unexplained infertility is defined as no detected abnormalities identified from standard infertility diagnostic testing).
 
NOTE: Contraindications include: active cervical, uterine or pelvic infection; absence of uterus; bilateral fallopian tube obstruction or absence; bilateral absence of ovaries; or other known causes of complete anovulation.
 
If conception does not occur after the initial 6 cycles* of intrauterine or intracervical insemination, up to 6 additional cycles may be eligible for benefits.
 
 
Does Not Meet Primary Coverage Criteria Or Is Not Medically Necessary For Contracts Without Primary Coverage Criteria
 
Intrauterine or intracervical insemination for indications other than those listed above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness, including, but not limited to, the following:
 
1. Infertility as a result of voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used;
4. One of the covered persons has had three live births by any means; OR
5. Presence of any one of the following contraindications: active cervical, uterine or pelvic infection; absence of uterus; bilateral fallopian tube obstruction or absence; bilateral absence of ovaries; or other known causes of complete anovulation.
 
For members with contracts without primary coverage criteria, intrauterine or intracervical insemination for indications other than those listed above as covered is considered not medically necessary:
 
1. Infertility as a result of voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. One of the covered persons has had three live births by any means.
5. Presence of any one of the following contraindications: active cervical, uterine or pelvic infection; absence of uterus; bilateral fallopian tube obstruction or absence; bilateral absence of ovaries; or other known causes of complete anovulation.
 
III. ASSISTED REPRODUCTIVE TECHNOLOGY (IN-VITRO FERTILIZATION)
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Assisted Reproductive Technology (In Vitro Fertilization) meets member benefit certificate primary coverage criteria and is covered provided other less invasive therapies, where appropriate, have failed (e.g., intrauterine insemination):
  
A. When the member and the member’s spouse have a history of unexplained infertility of at least two years duration;
 
OR
 
B. The member or the member’s spouse has infertility associated with one or more of the following medical conditions:
 
1. Stage 4 surgically treated endometriosis; or
2. Exposure in utero to diethylstilbestrol, commonly known as DES; or
3. Blockage or removal of one or both fallopian tubes, not as a result of voluntary sterilization; or
4. Untreatable, abnormal male factors contributing to infertility not as a result of voluntary sterilization  (e.g., untreatable retrograde ejaculation, untreatable penectomy, refractory erectile dysfunction); or
5. Cervical factor infertility; or
6. Vaginismus preventing intercourse; or
7. Anovulatory females who have failed to conceive after a 6 month trial of ovulation induction with timed intercourse under the supervision and monitoring of a physician; or
8. Absence or abnormality of uterus that precludes conception with evidence of intact ovarian function;  
 
AND
 
The in vitro fertilization procedures are performed by a physician who is board certified in reproductive endocrinology and infertility. NOTE: Related procedures (e.g., lab tests, ultrasounds) may be performed by a provider in consultation with the board certified or the IVF experienced physician.
  
*Preimplantation Genetic Diagnosis, Testing and Treatment is addressed in policy #2005021
 
Does Not Meet Primary Coverage Criteria Or Is Not Medically Necessary For Contracts Without Primary Coverage Criteria
 
Assisted Reproductive Technology (In Vitro Fertilization) does not meet member benefit certificate primary coverage criteria when either the member or the member’s spouse has:
 
1. Infertility as a result of a voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. When One of the covered persons has had three live births by any means.
 
For members with contracts without primary coverage criteria Assisted Reproductive Technology (In Vitro Fertilization) is considered not medically necessary when either the member or the member’s spouse has:
 
1. Infertility as a result of a voluntary sterilization; OR
2. Infertility resulting from natural age-related hormone reduction (I.e., postmenopausal or 45 years of age or older); OR
3. When a surrogate is used; OR
4. When One of the covered persons has had three live births by any means.
 
The following Assisted Reproductive Technology techniques do not meet member benefit certificate primary coverage criteria of effectiveness or are considered not medically necessary for members with contracts without primary coverage criteria:
 
    • assisted hatching (CPT code 89253);
    • co-culture of embryos (CPT code 89251);
    • cryopreservation of ovarian tissue or oocytes( CPT code 89240, 0058T, 0357T, 89337);
    • cryopreservation of testicular tissue in prepubertal boys(CPT code 89335);
    • storage and thawing of ovarian tissue, oocytes or testicular tissue (CPT codes 89344, 89346, 89354 and 89356)
 
Due to the detail of this policy, the document containing the coverage statements for dates prior to July 2021 is not online. If you would like a hardcopy print, please email: codespecificinquiry@arkbluecross.com
CPT/HCPCS:
0253UReproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive)
0255UAndrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, Fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score
54500Biopsy of testis, needle (separate procedure)
54800Biopsy of epididymis, needle
55400Vasovasostomy, vasovasorrhaphy
55870Electroejaculation
58321Artificial insemination; intra cervical
58322Artificial insemination; intra uterine
58323Sperm washing for artificial insemination
58340Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
58970Follicle puncture for oocyte retrieval, any method
58974Embryo transfer, intrauterine
58976Gamete, zygote, or embryo intrafallopian transfer, any method
58999Unlisted procedure, female genital system (nonobstetrical)
76948Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
82166Anti mullerian hormone (AMH)
89240Unlisted miscellaneous pathology test
89250Culture of oocyte(s)/embryo(s), less than 4 days;
89251Culture of oocyte(s)/embryo(s), less than 4 days; with co culture of oocyte(s)/embryos
89253Assisted embryo hatching, microtechniques (any method)
89254Oocyte identification from follicular fluid
89255Preparation of embryo for transfer (any method)
89257Sperm identification from aspiration (other than seminal fluid)
89258Cryopreservation; embryo(s)
89259Cryopreservation; sperm
89260Sperm isolation; simple prep (eg, sperm wash and swim up) for insemination or diagnosis with semen analysis
89261Sperm isolation; complex prep (eg, Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis
89264Sperm identification from testis tissue, fresh or cryopreserved
89268Insemination of oocytes
89272Extended culture of oocyte(s)/embryo(s), 4 7 days
89280Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
89281Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
89290Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre implantation genetic diagnosis); less than or equal to 5 embryos
89291Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre implantation genetic diagnosis); greater than 5 embryos
89300Semen analysis; presence and/or motility of sperm including Huhner test (post coital)
89310Semen analysis; motility and count (not including Huhner test)
89320Semen analysis; volume, count, motility, and differential
89321Semen analysis; sperm presence and motility of sperm, if performed
89322Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger)
89329Sperm evaluation; hamster penetration test
89330Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
89331Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)
89335Cryopreservation, reproductive tissue, testicular
89337Cryopreservation, mature oocyte(s)
89342Storage (per year); embryo(s)
89343Storage (per year); sperm/semen
89344Storage (per year); reproductive tissue, testicular/ovarian
89346Storage (per year); oocyte(s)
89352Thawing of cryopreserved; embryo(s)
89353Thawing of cryopreserved; sperm/semen, each aliquot
89354Thawing of cryopreserved; reproductive tissue, testicular/ovarian
89356Thawing of cryopreserved; oocytes, each aliquot
89398Unlisted reproductive medicine laboratory procedure
S4011In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
S4013Complete cycle, gamete intrafallopian transfer (gift), case rate
S4014Complete cycle, zygote intrafallopian transfer (zift), case rate
S4015Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016Frozen in vitro fertilization cycle, case rate
S4017Incomplete cycle, treatment cancelled prior to stimulation, case rate
S4018Frozen embryo transfer procedure cancelled before transfer, case rate
S4020In vitro fertilization procedure cancelled before aspiration, case rate
S4021In vitro fertilization procedure cancelled after aspiration, case rate
S4022Assisted oocyte fertilization, case rate
S4023Donor egg cycle, incomplete, case rate
S4025Donor services for in vitro fertilization (sperm or embryo), case rate
S4026Procurement of donor sperm from sperm bank
S4027Storage of previously frozen embryos
S4028Microsurgical epididymal sperm aspiration (mesa)
S4030Sperm procurement and cryopreservation services; initial visit
S4031Sperm procurement and cryopreservation services; subsequent visit
S4035Stimulated intrauterine insemination (iui), case rate
S4037Cryopreserved embryo transfer, case rate
S4040Monitoring and storage of cryopreserved embryos, per 30 days
S4042Management of ovulation induction (interpretation of diagnostic tests and studies, non face to face medical management of the patient), per cycle
References: Farquhar C, Rishworth JR, Brown J, et al.(2013) Assisted reproductive technology: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD010537. DOI: 10.1002/14651858.CD010537.pub2.

Macer ML and Taylor HS.(2012) Endometriosis and Infertility: A review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am. 2012 December; 39(4): 535–549.

National Institute for Health and Clinical Excellence.(2013) Fertility. Assessment and treatment for people with fertility problems. February 2013. NICE clinical guideline 156.

The optimal evaluation of the infertile male: AUA best practice statement reviewed and validity confirmed 2011. American Urological Association. Accessed at https://www.auanet.org/education/guidelines/male-infertility-d.cfm. Last accessed May 21, 2015.

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