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

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.