For the purpose of this policy infertility is defined as an interruption, cessation, or disorder of body functions, systems, or organs of the reproductive tract which prevents an individual or couple from the conception of a child or the ability to carry a pregnancy to delivery after regular, unprotected sexual intercourse without medical intervention or as diagnosed by a licecensed physician based on the individual\s medical, sexual, and reproductive history, age, physical findings, and/or diagnostic testing.
Infertility may include:
Standard fertility preservation services mean procedures consistent with established medical practices and professional guidelines published by professional medical organizations, including the American Society for Clinical Oncology and the American Society for Reproductive Medicine.
Assisted Reproductive Technology (ART) includes all treatments or procedures that involve the in vitro (i.e., outside of the living body) handling of both human oocytes (eggs) and sperm, or embryos, for the purpose of establishing a pregnancy. Treatments and procedures include, but are not limited to:
Artificial Insemination is a procedure by which sperm is directly deposited into the vagina, cervix or uterus to achieve fertilization and pregnancy which may be reported as part of an assisted fertilization program.
Assisted reproductive technology services are generally excluded from standard medical-surgical contracts and are only eligible for reimbursement as noted below. However, all medical, surgical, and diagnostic services performed to diagnose and treat infertility short of assisted reproductive technologies as defined above may be covered unless the individual's contract contains exclusion with regard to the diagnosis and treatment of infertility.
When the benefit exists, all medical, surgical, and diagnostic services performed to diagnose and treat infertility, excluding assisted reproductive technologies as defined in this policy, may be considered medically necessary.
If the goal for the infertile individual is assisted reproductive technology services as described below, all subsequent related diagnostic, medical, and surgical services are considered part of assisted reproductive technology services.
Report the appropriate diagnosis code for ART, in order to distinguish them as services associated with an assisted reproductive program. Such services are non-covered when the individual does not have an assisted reproductive technology benefit.
In Vitro Fertilization (IVF): 35 Years of Age or Older
IVF may be considered medically necessary for an individual age 35 or older with ANY ONE (1) of the following conditions:
AND
IVF: 34 Years of Age or Younger
IVF may be considered medically necessary for an individual age 34 and younger with ANY ONE (1) of the following conditions:
AND
IVF not meeting the criteria as indicated in this policy is considered not medically necessary.
58974 |
S4011 |
S4015 |
S4016 |
S4017 |
S4020 |
S4021 |
Gamete Intrafallopian Transfer (GIFT)/Zygote Intrafallopian Transfer (ZIFT)
GIFT or ZIFT may be considered medically necessary when ALL of the following criteria are met:
GIFT/ZIFT not meeting the criteria as indicated in this policy is considered not medically necessary.
58976 |
S4013 |
S4014 |
|
|
|
|
Intracytoplasmic Sperm Injection (ICSI)
ICSI may be considered medically necessary when BOTH of the following criteria are met:
ICSI not meeting the criteria as indicated in this policy is considered not medically necessary.
89280 |
89281 |
|
|
|
|
|
Gamete/Oocyte Cryopreservation
Assisted reproductive technology for the purpose of gamete (oocyte or sperm) or embryo cryopreservation may be considered medically necessary when ANY of the following criteria are met:
Assisted reproductive technology for the purpose of gamete/oocyte cryopreservation is considered not medically necessary when the procedure is performed to provide donor oocytes.
Gamete or embryo cryopreservation not meeting the criteria as indicated in this policy is considered not medically necessary.
89258 |
89259 |
89337 |
89398 |
|
|
|
Tubal Embryo Transfer (TET)
TET may be considered medically necessary when the individual meets the definition of infertility and ALL of the following criteria are met:
TET not meeting the criteria as indicated in this policy is considered not medically necessary.
58976 |
|
|
|
|
|
|
Frozen Embryo Transfer (FET)
FET may be considered medically necessary when the individual meets the definition of infertility and EITHER of the following criteria is met:
FET not meeting the criteria as indicated in this policy is considered not medically necessary.
58974 |
58976 |
S4018 |
S4037 |
|
|
|
Ovulation Induction Management
Ovulation induction management performed without a face-to-face individual/physician encounter (e.g., conducted via telephone) for EITHER of the following may be considered medically necessary:
Ovulation induction management not meeting the criteria as indicated in this policy is considered not medically necessary.
Note: This service may be reported using an appropriate evaluation and management (E&M) procedure code; provided that there is individual/physician interaction and all of the components of the E&M code have been met.
Quantity Level Limit
When performed for the treatment of infertility, global payment without a face-to-face ovulation induction management is limited to twelve cycles within a twelve-month period.
Quantities of ovulation induction management cycles greater than those identified are considered not medically necessary.
S4023 |
S4042 |
|
|
|
|
|
Immunotherapy for Recurrent Fetal Loss
Immunologic-based therapies may be considered medically necessary to avoid recurrent spontaneous abortion.
Immunologic-based therapies not meeting the criteria as indicated in this policy is considered experimental/investigational (E/I) and therefore non-covered because the safety and and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
90283 |
|
|
|
|
|
|
Assisted Fertilization Procedures
The procedures listed on the Table Attachment, Table A, are assisted fertilization procedures that may be reported as part of an assisted fertilization program.
55870 |
58321 |
58322 |
58323 |
58970 |
58974 |
58976 |
76948 |
84702 |
89250 |
89253 |
89254 |
89255 |
89257 |
89258 |
89259 |
89260 |
89261 |
89264 |
89268 |
89272 |
89280 |
89281 |
89290 |
89291 |
89337 |
S4028 |
S4035 |
S4042 |
|
|
|
|
|
|
Laboratory Services
Refer to Table B, Laboratory Services, in the attachments for the quantity of laboratory services per cycle that may be considered medically necessary.
More than two (2) progesterone measurements may be considered medically necessary for infertile women with irregular and prolonged menstrual cycles.
For infertile women with regular menstrual cycles, a mid-luteal serum progesterone measurement (day 21 of a 28-day cycle) may be considered medically necessary.
For infertile women with irregular menstrual cycles, this test would need to be repeated at the mid-luteal phase and weekly thereafter until the next menstrual cycle starts.
Quantities of laboratory services that exceed the frequency guidelines listed on Table B, Laboratory Services, are considered not medically necessary.
76830 |
82670 |
83001 |
83002 |
84144 |
84702 |
|
Cryopreservation, Storage, Procurement, and Thawing
Charges for cryopreservation, storage, procurement, and thawing of specimens are generally facility charges which should be processed in accordance with the individual’s benefits:
89258 |
89259 |
89335 |
89337 |
89342 |
89343 |
89344 |
89346 |
89352 |
89353 |
89354 |
89356 |
89398 |
S4025 |
S4026 |
S4027 |
S4030 |
S4031 |
S4040 |
|
|
Gestational Carrier/Surrogate
Medical services or supplies rendered to a gestational carrier or surrogate may be considered medically necessary if the individual has ANY of the following indications:
Services provided to a surrogate or gestational carrier may be a benefit exclusion.
Medical services or supplies rendered to a gestational carrier or surrogate not meeting the criteria as indicated in this policy is considered not medically necessary.
The following reproductive techniques or services are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of these services cannot be established by the available published peer-reviewed literature:
88182 |
89240 |
89251 |
|
|
|
|
The following related services to reproductive technologies/techniques are considered not medically necessary:
54900 |
54901 |
58750 |
S9977 |
S9986 |
|
|
Refer to Pharmacy Policy J-1, Fertility - Commercial and Select Healthcare Reform Plans, for additional information.
Refer to Medical Policy L-115, Preimplantation Genetic Screening and Diagnosis for additional information.
American Society for Reproductive Medicine and Society for Assisted Reproductive Technology – 2019
In 2019, the American Society for Reproductive Medicine (ASRM) released a 2019 committee opinion on fertility preservation in [individuals] undergoing gonadotoxic therapy. The committee included several relevant opinions:
ASRM and joint ASRM/Society for Assisted Reproductive Technology (SART) opinions and recommendations on other assisted reproductive technologies are as follows:
Planned oocyte cryopreservation (OC) for preserving future reproductive potential (2018):
Assisted hatching (2014): Assisted hatching should not be used routinely for all patients undergoing IVF.
Blastocyst transfer (2013; reaffirmed in 2018): "Evidence supports blastocyst transfer in ‘good prognosis' [individuals]."
American College of Obstetricians and Gynecologists – 2016
The American College of Obstetricians and Gynecologists endorsed the 2013 ASRM-SART joint guidelines on mature oocyte cryopreservation. The endorsement was affirmed in 2016.
American Society of Clinical Oncology – 2018
The American Society of Clinical Oncology updated its 2013 guidelines (with no changes to its recommendations) on fertility preservation for [individual's] with cancer. The guidelines included the following recommendations for males and females, respectively.
Covered Diagnosis Codes
Z31.7 |
Z31.81 |
Z31.83 |
Z31.84 |
Z31.89 |
Z31.9 |
|
Non-Covered Diagnosis Codes for Procedure Codes: 54900, 54901, 58750
Z31.0 |
|
|
|
|
|
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
