1. health and fitness
2. disease
3. 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
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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