Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) Form



Intracytoplasmic Sperm Injection (ICSI)

Indications

(727374) Has the patient undergone two semen analyses prior to categorization of infertility? 
(727375) Is this ICSI cycle within the first three cycles per attempted pregnancy? 
(727376) Does the patient have severe infertility with any of the following parameters: asthenozoospermia, oligozoospermia, teratozoospermia? 
(727377) Has a previous IVF treatment cycle in the patient resulted in failed or poor fertilization? 
(727378) Have anti-sperm antibodies been documented in the patient? 
(727379) Does the patient have a spinal cord injury requiring electroejaculated sperm? 
(727380) Are surgically retrieved sperm (epididymal or testicular) being used for the ICSI? 
(727381) Is the patient using cryopreserved sperm post-cancer remission? 
(727382) Is preimplantation genetic testing (PGT) being completed alongside ICSI (e.g., for a single gene defect)? 

Contraindications

(727383) Are more than three cycles of ICSI being attempted per pregnancy? 

Intracytoplasmic Sperm Injection (ICSI) - not covered scenarios

Notes: When criteria for medical necessity are not met, the ICSI procedure is considered not medically necessary. Specific conditions that result in non-coverage include those listed.

Indications

(727384) Is the ICSI procedure being requested due reasons listed as 'not medically necessary,' such as unexplained infertility, tubal occlusion, advanced maternal age, low oocyte yield at retrieval, or routine insemination of oocytes for IVF? 

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the use of intracytoplasmic sperm injection (ICSI) during an infertility treatment cycle. This technique can allow some infertile individuals to attain live birth rates similar to those achieved with in vitro fertilization (IVF) using conventional methods of fertilization.

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

  • CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
  • CG-MED-88 Preimplantation Embryo Biopsy and Genetic Testing
  • CG-SURG-34 Diagnostic Hysteroscopy for Infertility
  • LAB.00045 Selected Tests for the Evaluation and Management of Infertility

Clinical Indications

Medically Necessary:

A maximum of three cycles of ICSI per attempted pregnancy is considered medically necessary in covered individuals who meet ANY of the following criteria:

  1. Severe infertility due to any of the following semen analysis parameters;
    1. Asthenozoospermia (less than 40% moving sperm) (see definition section); or
    2. Oligozoospermia (less than 15 million/ml); or
    3. Teratozoospermia (normal morphology in 4% or fewer observed sperm); or
  2. Previous IVF treatment cycle has resulted in failed or poor fertilization (equal to or greater than 50% of oocytes unfertilized in a prior cycle); or
  3. Anti-sperm antibodies have been documented; or
  4. Spinal cord injury individuals requiring electroejaculated sperm; or
  5. Surgically retrieved sperm (epididymal or testicular); or
  6. When using cryopreserved sperm for individuals in remission from cancer; or
  7. When completing preimplantation genetic testing (PGT) (for example, for single gene defect).

Note:  Two semen analyses are required prior to categorization of the infertility. A comprehensive semen analysis must be completed prior to infertility treatment cycles.

Not Medically Necessary:

  1. More than three cycles of ICSI per attempted pregnancy is considered not medically necessary.
  2. ICSI is considered not medically necessary when the criteria above are not met including, but not limited to all of the following:
    1. Unexplained infertility;
    2. Tubal occlusion;
    3. Advanced maternal age;
    4. Low oocyte yield at retrieval;
    5. Routine insemination of oocytes for IVF.