Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut LAB.00045 Selected Tests for the Evaluation and Management of Infertility Form

Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses selected tests that are part of the diagnostic work-up to determine the cause of infertility or manage infertility treatment.

Note: In this guideline, the term ‘‘male’’ or ‘‘men’’ is used to refer to genetic or biological men. The term “female” or “women” is used to refer to genetic or biological women.

Note: Please see the following related documents for additional information:

  • CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
  • CG-SURG-34 Diagnostic Hysteroscopy for Infertility
  • CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)

Position Statement

Investigational and Not Medically Necessary:

The following tests or procedures are considered investigational and not medically necessary for diagnosing or managing infertility:

  • Endometrial receptivity analysis;
  • Sperm-capacitation test;
  • Sperm deoxyribonucleic acid (DNA) fragmentation test;
  • Sperm penetration assay; and
  • Uterine natural killer (uNK) cells test.