TREATMENT OF INFERTILITY •
CLINICAL POLICY TREATMENT OF INFERTILITY Policy Number: INFERTILITY 001.21 T2 Effective Date: September 1, 2014 Table of Contents Page CONDITIONS OF COVERAGE.................................... BENEFIT CONSIDERATIONS…………………..…….. COVERAGE RATIONALE………………………...…… DEFINITIONS………………………………………….... APPLICABLE CODES.................................................. DESCRIPTION OF SERVICES……………………….. REFERENCES............................................................. POLICY HISTORY/REVISION INFORMATION........... Policy History Revision Information 1 2 4 6 7 9 9 10 Related Policies: • Clinical Review Policy • Diagnostic (Basic) Procedures for Infertility • Experimental / Investigational Treatment • Follicle Stimulating Hormones (FSH) Used in the Treatment of Infertility • Infertility Procedures Requiring Notification and/or Precertification • Treatment of Infertility for Connecticut Groups • Treatment of Infertility for New Jersey Large Groups • Treatment of Infertility for New Jersey Small Groups and New Jersey Individual Plans • Treatment of Infertility for New York Large and Small Groups The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. CONDITIONS OF COVERAGE Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan and Oxford USA plan membership excluding: • New Jersey Large - please refer to Treatment of Infertility for New Jersey Large Groups. 1 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC Applicable Lines of Business/ Products (continued) Benefit Type Referral Required • New York Large and Small (excluding Healthy New York Plans) - please refer to Treatment of Infertility for New York Large and Small Groups. • Connecticut Large and Small - please refer to Treatment of Infertility for Connecticut Groups. • New Jersey Small Group Plans (except NJ Small Plan A) - please refer to Treatment of Infertility for New Jersey Small Groups and New Jersey Individual Plans. • The below Lines of Business (LOBs) do NOT have infertility benefits beyond what is covered under diagnostic (basic) coverage and are excluded from coverage. Please refer to policy Diagnostic (Basic) Procedures for Infertility: o All Healthy NY Plans o All NY Individual plans o NJ Small Plan A o NJ Individual Plans with plan years that begin prior to January 1, 2014 1, 2 Infertility benefit 3 Pharmacy benefit 4 Yes (Does not apply to non-gatekeeper products) Authorization Required Yes (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service 5 No Outpatient, Office (If site of service is not listed, Medical Director review is required) 1 Special Considerations The Member may or may not have coverage for out-ofnetwork treatment. 2 Advanced Infertility benefits are specific to each group. Refer to Member's benefits. 3 Pharmacy benefit with coverage for injectable infertility medications. 4 Referral is ONLY required if the treating physician is NOT the OBGYN of record. 5 Precertification with MD review is required for any code listed in the non-covered grid and may be required for codes in the covered grid. Note: • • Oxford has engaged Optum to perform reviews of requests for pre-certification. To pre-certify a procedure related to the treatment of infertility, please call Optum at 877-512-9340. Oxford continues to be responsible for decisions to limit or deny coverage and for appeals. BENEFIT CONSIDERATIONS • • Diagnosis of infertility is a covered benefit for all plans. Refer to Diagnostic (Basic) Procedures for Infertility. Treatment of infertility is not a covered benefit for all plans. Refer to Member's benefits. 2 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC • • • • • • • Therapeutic (surgical and non-surgical) procedures to correct a physical condition which is the underlying cause of the infertility are covered under the General benefits package. An Infertility benefit is not required for coverage of these services (e.g. for the treatment of a pelvic mass or pelvic pain). However, surgical procedures specific to the treatment of infertility (e.g. fimbrioplasty, treatment of minimal or mild endometriosis or lysis of adhesions in the absence of pain) require an infertility benefit. Assisted reproductive technologies (ART) require an infertility benefit and not all groups or plans have coverage for assisted reproductive services; additionally some groups have coverage for mid-level infertility techniques, but not for advanced services. Refer to the Member's benefits. For those plans that have infertility coverage, the infertility benefit has specific dollar and/or procedural coverage limitations based on the Member's individual coverage. Members should refer to their Certificate of Coverage for their specific coverage and their Summary of Benefits for out of pocket expenses including maximums and benefit limitations. If the Member's coverage is subject to a pre-existing condition limitation, infertility will be considered a pre-existing condition (except for CT). Religious employer exemptions may apply: A religious employer may request a contract without coverage for infertility services (e.g., in vitro fertilization, embryo transfer, artificial insemination and intracytoplasmic sperm injection [ICSI]) that are contrary to the religious employer's bona fide religious tenets. Refer to Member's benefits. Self-funded groups may or may not choose to offer infertility coverage. Refer to Member's benefits. Eligibility: In order to be eligible for infertility benefit coverage the Member must meet infertility, age and coverage criteria listed below. Once eligibility criteria have been met further treatment is subject to the Optum Infertility Clinical Guidelines. 1. Infertility Criteria: o o o o o Inability to achieve pregnancy after 12 months of unprotected heterosexual intercourse or physician supervised therapeutic donor insemination if less than 35 years of age; or Women aged 35 and older who are unable to achieve pregnancy after 6 months of unprotected heterosexual intercourse or physician supervised therapeutic donor insemination; or Women who have not met time criteria for failure to conceive, but who have a documented anatomic variant or other medical condition (therefore an anovulatory woman does not need to wait 12 months) resulting in the inability to achieve pregnancy (e.g., severe pelvic inflammatory disease, endometriosis, or ectopic pregnancy requiring surgical removal of both fallopian tubes); or Women with recurrent pregnancy loss (see definition of infertility); or Males with anatomical variants such as aspermia or varicocele resulting in an inability to reproduce. 2. Age criteria [applies to Member being treated (male or female)]: o o Minimum age is 21 years; and Maximum age is 44 years Exception: If an eligible Member has initiated a cycle of treatment and, by virtue of having a birthday, exceeds the maximum eligible age prior to completion of the cycle, the treatment will be covered to the nearest logical endpoint: • • For Artificial Insemination: Ovarian stimulation initiated prior to birthday and subsequent insemination will be covered. Other Advanced Procedures: (e.g. IVF, GIFT, etc): Cycle stimulation initiated prior to birthday, subsequent ovum retrieval, fertilization, culture and embryo transfer will be covered unless the benefit has been exceeded. 3 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC 3. Coverage criteria: o o Treatment is limited to Oxford insured Members; and Benefit has not been exceeded; and Note: Benefits are defined by the number of procedures and/or by financial caps. Once the maximum benefit (as defined by the Member's plan) has been reached, there is no extension of service, even if cycle stimulation has been initiated. o Preexisting conditions does not apply Note: Congenital abnormalities may not be excluded as a preexisting condition. COVERAGE RATIONALE Oxford has engaged Optum to perform reviews of requests for the treatment of infertility. Optum has established an infrastructure to support the review, development, and implementation of comprehensive clinical guidelines. The guidelines are available on the Optum web site: https://www.myOptumcomplexmedical.com/gateway/public/infertility/productsAndServices.jsp Covered services are subject to medical necessity review* and will be determined based upon review of the members benefit, Oxford Policies and Optum's Infertility Clinical Guidelines. We reserve the right to provide coverage for a requested service in the manner we determine to be medically appropriate/medically effective and the most cost effective. Covered services must be performed at facilities that conform to the standards of the American Society of Reproductive Medicine or the American College of Obstetricians and Gynecologists. Comprehensive and Advanced Level Techniques must be performed only by or under the supervision of a Board Certified or eligible Reproductive Endocrinologists. *For additional information regarding medical necessity review, refer to Oxford’s Clinical Review Policy. Procedures to Treat Infertility (subject to medical necessity review): Infertility treatments include comprehensive level techniques, also referred to as mid-level (from ovarian stimulation up to and including artificial insemination) and advanced level techniques [Assisted Reproductive Technologies (ART)]. Comprehensive Level Techniques (also referred to as mid-level): • Ovulation induction with oral or injectable medications; • Controlled ovarian stimulation with oral medications; • Cervical or Intrauterine artificial insemination; • Sperm washing; • Sperm isolation; simple prep (e.g. sperm wash and swim up); • Sperm isolation; complex prep (e.g. Percoll gradient, albumin gradient); • Electroejaculation. Advanced Level Techniques: • In vitro fertilization (IVF); 4 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC • Gamete intrafallopian transfer (GIFT); • Ultrasonic guidance for aspiration of ova, imaging and supervision; • Oocyte identification from follicular fluid; • Fertilization of oocyte(s); • Intracytoplasmic sperm injection (ICSI); • Microscopic epididymal sperm aspiration (MESA); • Testicular sperm aspiration (TESA); • Percutaneous epididymal sperm aspiration (PESA); • Sperm identification from aspiration (other than seminal fluid); • Culture of /embryo(s); • Assisted embryo hatching, microtechniques; • Thawing of cryopreserved oocyte(s)/embryo(s); • Preparation of embryo for transfer (any method); • Embryo transfer; o Previously frozen embryo(s) must be transferred prior to another fresh egg retrieval • Fertility preservation prior to gonadotoxic treatment including sperm, mature egg (women under the age of 42) or embryo cryopreservation with storage up to one year; • Egg donation: fertilization of the oocyte through embryo transfer when otherwise not covered but medically necessary; • IVF for a female without a male partner: IVF would be covered in a female without a male partner only if IVF is otherwise medically indicated and the resulting embryos are transferred only to the originator of the eggs. Non-Covered Services Treatments not covered by Oxford are as follows: • Non-medical costs for an ovum donor or sperm donor; • Sperm, embryo(s), reproductive tissue, testicular/ovarian, oocyte storage costs; • Cryopreservation of embryos, oocytes (eggs), sperm or other reproductive tissue; • Ovulation predictor kits; • Reversal of permanent sterilization procedures; • Cloning; • Any infertility services if the Member has undergone a voluntary sterilization procedure (tubal ligation, fulguration, vasectomy, Essure® insertion): o o Coverage may be provided, if a member has undergone a sterilization reversal with subsequent documented patency of the fallopian tubes or presence of viable sperm in an ejaculate and additionally meets the definition of infertility’ If the partner (who is a covered member) of the member who has been sterilized meets the definition of infertility, that partner may be eligible for coverage for their specific infertility condition only’ 5 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC Example: Male has had a vasectomy that has not been reversed. His female covered partner is anovulatory. Coverage may be provided for ovulation induction only. • All costs associated with gestational carriers and surrogacy;* *Note: Maternity services are covered for Oxford Members acting as surrogates. • Experimental procedures and treatments; refer to policy titled Experimental/Investigational Treatment. DEFINITIONS Infertility and Recurrent Pregnancy Loss: Infertility is a disease defined by the failure to achieve a successful pregnancy after 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 6 months* for women over age 35 years. Recurrent pregnancy loss is a disease distinct from infertility, defined by two or more failed pregnancies. When the cause is unknown, each pregnancy loss merits careful review to determine whether specific evaluation may be appropriate. (ARSM, 2012) *Note: The waiting period may be eliminated in the presence of known infertility factors including but not limited to: • • • • congenital malformations known male factor known ovulatory disorders documented compromise of the fallopian tubes Optum Infertility Clinical Guidelines: Utilize scientific evidence to determine whether the proposed health care services or the services provided for a patient are medically necessary (i.e., supported by published clinical evidence, the most appropriate service for the unique patient and/or the most cost-effective service under the specific circumstances). Guidelines may be used to determine: a. b. c. d. Patient selection criteria; Appropriateness of treatment Level of care or site of service Whether diagnostic and therapeutic procedures of lower resource intensity should be used prior to those of a higher intensity of medical service (i.e., conservative therapy before a surgical procedure). Utilization Review (UR): The review to determine whether Health Care Services that have been provided (Retrospective), are being provided (Concurrent) or are proposed to be provided (Precertification) are Medically Necessary. APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member’s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive. *Codes below marked with (*) are covered for NJ Large group plans. 6 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC Covered Codes ® CPT Code 52402 55200 55300 55550 55870 58321 58322 58323 58340 58345 58350 58559 58560 58662 58700 58720 58740 58752 58760 58770 58970 58974 58976 76948 82670 83001 83002 88272 89290 89250 89253 89254 89255 89257 89260 89261 89264 89268 89272 89280 Description Cystourethroscopy with transurethral resection or incision of ejaculatory ducts Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral Laparoscopy, surgical, with ligation of spermatic veins for varicocele Electroejaculation Artificial insemination; intra-cervical Artificial insemination; intra-uterine Sperm washing for artificial insemination Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography Transcervical introduction of fallopian tube catheter for diagnosis and/or reestablishing patency (any method), with or without hysterosalpingography Chromotubation of oviduct, including materials Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) Lysis of adhesions (salpingolysis, ovariolysis) Tubouterine implantation Fimbrioplasty Salpingostomy (salpingoneostomy) Follicle puncture for oocyte retrieval, any method Embryo transfer, intrauterine Gamete, zygote, or embryo intrafallopian transfer, any method Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation Estradiol Gonadotropin; follicle stimulating hormone (FSH) Gonadotropin; luteinizing hormone (LH) Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (e.g., for derivatives and markers) Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos Culture of oocyte(s)/embryo(s), less than 4 days; Assisted embryo hatching, microtechniques (any method) Oocyte identification from follicular fluid Preparation of embryo for transfer (any method) Sperm identification from aspiration (other than seminal fluid) Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis Sperm identification from testis tissue, fresh or cryopreserved Insemination of oocytes Extended culture of oocyte(s)/embryo(s), 4-7 days Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes 7 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC ® CPT Code 89281 89290 89291 89352 HCPCS Code S4011 S4013 S4014 S4015 S4016 S4017 S4018 S4020 S4021 S4022 S4023 S4028 S4035 S4037 S4042 Description Assisted oocyte fertilization, microtechnique; greater than 10 oocytes Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); greater than 5 embryos Thawing of cryopreserved; embryo(s) Description In 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 Complete cycle, gamete intrafallopian transfer (GIFT), case rate Complete cycle, zygote intrafallopian transfer (ZIFT), case rate Complete in vitro fertilization cycle, not otherwise specified, case rate Frozen in vitro fertilization cycle, case rate Incomplete cycle, treatment cancelled prior to stimulation, case rate Frozen embryo transfer procedure cancelled before transfer, case rate In vitro fertilization procedure cancelled before aspiration, case rate In vitro fertilization procedure cancelled after aspiration, case rate Assisted oocyte fertilization, case rate Donor egg cycle, incomplete, case rate Microsurgical epididymal sperm aspiration (MESA) Stimulated intrauterine insemination (IUI), case rate Cryopreserved embryo transfer, case rate Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management of the patient), per cycle CPT® is a registered trademark of the American Medical Association. Non-Covered Codes ® CPT Code 55400 58750 89251 89258* 89259* 89329 89335 89342 89343 89344 89346 89353 89354 89356 0058T 0059T 0357T Description Vasovasostomy, vasovasorrhaphy Tubotubal anastomosis Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos Cryopreservation; embryo(s) Cryopreservation; sperm Sperm evaluation; hamster penetration test Cryopreservation, reproductive tissue, testicular Storage (per year); embryo(s) Storage (per year); sperm/semen Storage (per year); reproductive tissue, testicular/ovarian Storage (per year); oocyte(s) Thawing of cryopreserved; sperm/semen, each aliquot Thawing of cryopreserved; reproductive tissue, testicular/ovarian Thawing of cryopreserved; oocytes, each aliquot Cryopreservation; reproductive tissue, ovarian Cryopreservation; oocyte(s) Cryopreservation; immature oocyte(s) 8 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC HCPCS Code J1380 S0122 S0132 S4025* S4026 S4027 S4030 S4031 S4040 Description Injection, estradiol valerate, up to 10 mg Injection, menotropins, 75 IU Injection, ganirelix acetate, 250 mcg Donor services for in vitro fertilization (sperm or embryo), case rate Procurement of donor sperm from sperm bank Storage of previously frozen embryos Sperm procurement and cryopreservation services; initial visit Sperm procurement and cryopreservation services; subsequent visit Monitoring and storage of cryopreserved embryos, per 30 days CPT® is a registered trademark of the American Medical Association. DESCRIPTION OF SERVICES Approximately 10-15% of American couples experience infertility. A female factor is responsible for approximately 50% of cases, while male factors account for up to 30%. Multiple causes are found in a number of cases. In up to 15% of cases, no obvious cause can be identified. REFERENCES 1. American Medical Association. CPT Professional Edition. 2. American Medical Association. Healthcare Common Procedure Coding System. Medicare's National Level II Codes HCPCS. 3. Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology & Infertility. 6th Edition. Philadelphia: Lippencott, Williams, & Wilkins, 1999. 4. Carson DS, Bucci KK. Infertility in women: an update. J Am Pharm Assoc. 1998 Jul-Aug; 38(4): 480-6. 5. Centers for Disease Control and Prevention, American Society for Reproductive Medicine, and RESOLVE-1996. Assisted reproductive technology success rates: national summary and fertility clinic reports. Atlanta, GA: Centers for Disease Control and Prevention, 1998. 6. Hanson MA, Dumesic DA. Initial evaluation and treatment of infertility in a primary care setting. Mayo Clin Proc. 1998 Jul; 73(7): 681-5. 7. La Sala GB, Montanari R, Dessanti L, et al. The role of diagnostic hysteroscopy and endometrial biopsy in assisted reproductive technologies. Fertil Steril. 1998 Aug; 70(2): 37880. 8. American College of Obstetricians and Gynecologists. Guidelines for women's health care, 1996. 9. Mosgaard B, Hertz J, Steenstrup BR, et al. Surgical management of tubal infertility: a regional study. Acta Obstet Gynecol Scand. 1996; 75(5): 469-74. 10. Silverberg KM. Ovulation induction in the ovulatory woman. Sem Reprod Endocrinol. 1996; 14(4): 339-44. 11. American College of Obstetricians and Gynecologists. Infertility. ACOG Technical Bulletin #125, 1989. 12. The Certificates and Riders (NY, CT and NJ Large). 13. CMS Intermediary Manual Part 3. Chapter II-Coverage of Services. Section 3101.13. 14. NY Ins. Law §3221 6(A). 15. New Jersey 17B: 27-46.1x. 9 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC 16. American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril. 2013 Jan;99(1):63. POLICY HISTORY/REVISION INFORMATION Date • • • 09/01/2014 Action/Description Reorganized policy content Replaced references to “OptumHealth” with “Optum” Revised benefit considerations: o Added language to indicate: Therapeutic (surgical and non-surgical) procedures to correct a physical condition which is the underlying cause of the infertility are covered under the General benefits package; an Infertility benefit is not required for coverage of these services (e.g., for the treatment of a pelvic mass or pelvic pain) however, surgical procedures specific to the treatment of infertility (e.g., fimbrioplasty, treatment of minimal or mild endometriosis or lysis of adhesions in the absence of pain) require an infertility benefit Assisted reproductive technologies (ART) require an infertility benefit and not all groups or plans have coverage for assisted reproductive services; additionally some groups have coverage for mid-level infertility techniques, but not for advanced services (refer to the Member's benefits) o Modified eligibility guidelines: Added language to clarify once eligibility criteria have been met, further treatment is subject to the Optum Infertility Clinical Guidelines Updated/expanded infertility criteria: - Replaced: • “Inability to achieve pregnancy after 12 months of unprotected heterosexual intercourse” with “inability to achieve pregnancy after 12 months of unprotected heterosexual intercourse or physician supervised therapeutic donor insemination if less than 35 years of age” • “Women aged 35 and older who are unable to achieve pregnancy after 6 months of unprotected heterosexual intercourse” with “women aged 35 and older who are unable to achieve pregnancy after 6 months of unprotected heterosexual intercourse or physician supervised therapeutic donor insemination” • “Women who have not met time criteria for failure to conceive, but who have a documented anatomic variant resulting in the inability to achieve pregnancy” with “women who have not met time criteria for failure to conceive, but who have a documented anatomic variant or other medical condition (therefore an anovulatory woman does not need to wait 12 months) resulting in the inability to achieve pregnancy” - Added: • Women with recurrent pregnancy loss 10 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC Date Action/Description Removed: • Women with documented follicle stimulating hormone (FSH) levels less than or equal to 19 mIU/ml on day 3 of the menstrual cycle Updated age criteria; revised exception language for: - Artificial Insemination: Removed reference to “ovulation induction in progress” - Other Advanced Procedures: Removed reference to “cycle stimulation in progress” Updated coverage criteria: - Removed language indicating infertility may not be considered pre-existing in CT Removed prior procedure criteria Reorganized and revised coverage rationale: o Added language to indicate: Covered services are subject to medical necessity review* and will be determined based upon review of the members benefit, Oxford Policies and Optum's Infertility Clinical Guidelines; we reserve the right to provide coverage for a requested service in the manner we determine to be medically appropriate/medically effective and the most cost effective Covered services must be performed at facilities that conform to the standards of the American Society of Reproductive Medicine or the American College of Obstetricians and Gynecologists Comprehensive and Advanced Level Techniques must be performed only by or under the supervision of a Board Certified or eligible Reproductive Endocrinologists *For additional information regarding medical necessity review, refer to the policy titled Clinical Review o Revised guidelines for Procedures to Treat Infertility (subject to medical necessity review) to indicate infertility treatments include comprehensive level techniques, also referred to as mid-level (from ovarian stimulation up to and including artificial insemination) and advanced level techniques [Assisted Reproductive Technologies (ART)] Updated list of Comprehensive (Mid-Level) Techniques: - Replaced: • “Cycle stimulation (ovulation induction) with oral or injectable medications” with “ovulation induction with oral or injectable medications” • “Intrauterine artificial insemination” with “cervical or intrauterine artificial insemination” Added: • Controlled ovarian stimulation with oral medications • Electroejaculation - Removed: • Sperm evaluation; hamster penetration test Updated list of Advanced Level Techniques: - Replaced: • “Culture of oocyte(s)/embryo(s)” with “culture of embryo(s)” - • 11 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC Date Action/Description “Thawing of cryopreserved embryo(s)” with “thawing of cryopreserved oocyte(s)/embryo(s)” - Added: • Oocyte identification from follicular fluid • Embryo transfer • Fertility preservation prior to gonadotoxic treatment including sperm, mature egg (women under the age of 42) or embryo cryopreservation with storage up to one year • Egg donation: fertilization of the oocyte through embryo transfer when otherwise not covered but medically necessary • IVF for a female without a male partner: IVF would be covered in a female without a male partner only if IVF is otherwise medically indicated and the resulting embryos are transferred only to the originator of the eggs - Removed: • Assisted oocyte fertilization, micro-technique o Revised list of Non-Covered Services: Replaced: - “Cost of donor sperm or an ovum donor when oocyte retrieved from someone other than recipient” with “non-medical costs for an ovum donor or sperm donor” - “All costs associated with surrogate motherhood” with “ All costs associated with gestational carriers and surrogacy” Added: - Experimental procedures and treatments; refer to policy titled Experimental/Investigational Treatment Removed: - Sex change procedures - Services for partner and spouses, and the maternity expenses of gestational carriers not insured by Oxford Expanded: “Any infertility treatment if Member has undergone voluntary sterilization procedure (tubal ligation, ® fulguration, vasectomy, Essure insertion)” to include language indicating: • Coverage may be provided, if a member has undergone a sterilization reversal with subsequent documented patency of the fallopian tubes or presence of viable sperm in an ejaculate and additionally meets the definition of infertility • If the partner (who is a covered member) of the member who has been sterilized meets the definition of infertility, that partner may be eligible for coverage for their specific infertility condition only Added definition of: o Infertility and recurrent pregnancy loss o Optum Infertility Clinical Guidelines o Utilization Review (UR) • • 12 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC Date • • • • Action/Description Updated list of applicable CPT codes: o Covered: Added 58559, 58560 and 58662 o Non-Covered: Added 0357T Updated list of applicable HCPCS codes: o Covered: Added S4037 (previously listed as non-covered) o Non-Covered: Removed J0725 Updated supporting information to reflect the most current description of services and references Archived previous policy version INFERTILITY 001.21 T2 13 Treatment of Infertility: Clinical Policy (Effective 09/01/2014) ©1996-2014, Oxford Health Plans, LLC
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