Infertility and Recurrent Pregnancy Loss Testing and Treatment Form
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Infertility and Recurrent Pregnancy Loss Testing and Treatment Medical Guideline
Service: Infertility and Recurrent Pregnancy Loss Testing and Treatment
PUM 250-0018
Medical Guideline Committee Approval Q4-2025 Effective Date 03/01/2026
Coverage for Infertility and recurrent pregnancy loss testing and treatment may vary across plans. Refer to the member’s benefit plan document for coverage details.
Note: Refer to the member health plan for definitions, exclusions, benefits, and preauthorization requirements for the diagnosis and treatment of infertility and / or recurrent pregnancy loss. Including: determining the cause (etiology) of the condition, treatment of the presumed cause of the condition, limits to the number of courses of treatment (such as courses of in-vitro fertilization), treatment related to voluntary sterilization or failed reversal of voluntary sterilization, and whether complications related to a non-covered service are a benefit.
Infertility treatments are procedures that are considered experimental, investigational, or unproven to affect health or pregnancy outcomes are not covered, regardless of health plan infertility benefits. Procedures, treatments, and services considered experimental, investigational, or unproven are considered General Exclusions of the health plan.
Genetic tests (when a covered benefit of the individual’s plan) require medical necessity review and must meet test validity and medical necessity criteria for the condition.
Cystic Fibrosis (CF) diagnostic testing and spinal muscular atrophy (SMA) diagnostic testing require medical necessity review.
Preconception or prenatal screening for Cystic Fibrosis (CF), with targeted mutation analysis of 23 CFTR mutations, and spinal muscular atrophy (SMA), with SMN1 and SMN2 genes as endorsed by the American College of Medical Genetics and Genomics (ACMG), and American College of Obstetricians and Gynecologists (ACOG) guidelines are considered medically necessary regardless of infertility benefit.
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Description:
Infertility: When not defined by the member’s health plan, infertility is defined as the physical inability to achieve a pregnancy after twelve months of regular, unprotected intercourse if the woman is under age 35; or after six months, if the woman is over age
-
When not specified by the member’s health plan, the diagnostic phase includes efforts to determine the cause of infertility up until infertility treatment is started. Once a patient is prescribed an ovulation inducing medication (e.g., Clomid), she is in the therapeutic stage of infertility (and is no longer in the diagnostic stage).
Recurrent Pregnancy Loss (RPL): When not defined by the health plan, RPL is defined as two or more failed clinical pregnancy outcomes (includes ectopic pregnancy) documented by ultrasonography or histopathologic examination.
Indications of Coverage:
I. Infertility
If the individual’s plan has a benefit for testing to determine the cause of infertility, the following services may be considered medically necessary when performed strictly for diagnostic purposes:
A. History and physical examination
B. Laboratory tests as appropriate, including: Antimullerian hormone (AMH); Thyroid stimulating hormone (TSH); prolactin; follicle stimulating hormone (FSH); luteinizing hormone (LH); estradiol; progesterone; total and free testosterone; anti-sperm antibodies; post-ejaculatory urinalysis; semen analysis of two semen specimens (at least one month apart) to evaluate semen volume, concentration, motility, pH, fructose, leukocyte count, microbiology, and morphology.
C. Ultrasound of the pelvis
D. Hysteroscopy
E. Hysterosalpingography
F. Sonohysterography
G. Diagnostic laparoscopy with or without chromotubation
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H. Trans rectal ultrasound (TRUS), scrotal ultrasound
I. Vasography and testicular biopsy in individuals with azoospermia (absence of sperm)
J. Scrotal exploration
K. Prenatal or preconception CTFR Gene and Mutation Carrier genetic testing for cystic fibrosis, and SMN1and SMN2 gene analysis for spinal muscular atrophy are covered services, regardless of infertility benefits.
L. Karyotyping for chromosomal abnormalities in individuals with nonobstructive azoospermia (absence of sperm) or severe oligospermia (sperm concentration less than 5 million/mL)
M. Y-chromosome microdeletion testing for individuals when all of the following (1 through 3 below) are met:
The individual has non-obstructive azoospermia or severe oligospermia, (sperm concentration less than 5 million/mL) AND
Cytogenic karyotyping (chromosome analysis) is negative for chromosomal abnormalities associated with infertility (e.g., negative for Klinefelter Syndrome) AND
The individual has no evidence of hypogonadotropic hypogonadism (no evidence of Kallman syndrome)
N. If infertility treatment is a benefit of the plan: Sperm penetration assay (hamster penetration test, zona free hamster oocyte test) for those with male factor infertility, who are considering in vitro fertilization (IVF) cycles and intracytoplasmic sperm injection (ICSI)
II. Recurrent Pregnancy Loss:
If testing and / or treatment for recurrent pregnancy loss is a benefit of the individual’s health plan, the following services may be considered medically necessary after two or more pregnancy losses:
A. Testing
Standard-resolution peripheral karyotypic analysis of parents, to include tissue culture and cytogenetic testing of parental tissue.
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Screening for lupus anticoagulant
Screening for anticardiolipin antibodies (IgG, IgM) and lupus anticoagulant using standard assays
Anti-B2 glycoprotein I
Sonohysterogram, hysterosalpingogram, and/or hysteroscopy
Screening for thyroid or prolactin abnormalities
Pelvic ultrasound to assess uterine anatomy and morphology (if not performed with a previous pregnancy)
Chromosomal microarray analysis on products of conception (POC) may be considered medically necessary when ONE of the following is met:
• The member has a pregnancy loss at 20 weeks of gestation or earlier and has a history of recurrent miscarriage (defined as having two or more failed clinical pregnancies including the current loss) OR • The member has a pregnancy loss after 20 weeks of gestation such as intrauterine fetal demise (IUFD) or stillbirth.
***Please note that karyotypic analysis (chromosome analysis) of products of conception is considered medically necessary for any pregnancy loss
B. Any treatable cause of Recurrent Pregnancy Loss would be considered medically necessary and not fall under “infertility benefits”. Examples of treatable causes include but are not limited to, appropriate control of overt diabetes mellitus, thyroid dysfunction, Poly Cystic Ovary Syndrome (PCOS), surgical treatment of structural uterine abnormalities including endometriosis treatments or other treatments which may be a cause of infertility but also give other symptoms, and treatment of clearly established antiphospholipid syndrome (APS).
Limitations of Coverage:
Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do
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intend to limit a list of services or examples, we state specifically that the list “is limited to.”
A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.
B. Tests may be repeated once in the diagnostic workup for infertility testing. Additional testing after the initial and repeat tests is considered not medically necessary.
C. Endometrial Receptivity Analysis (ERA) such as Igenomix testing designed to determine the optimal timing of embryo transfer, is considered experimental, investigational, and unproven and/or subject to the infertility treatment benefits/exclusions of the health plan.
D. Cryopreservation of sperm / ova (also known as elective fertility preservation, embryo accumulation / banking procedures): If not considered an exclusion of the health plan, is considered not medically necessary per the health plan definition.
E. When preimplantation genetic testing is planned, assisted reproductive technology (ART) must be used for conception (even if infertility is not an issue for the couple). Consequently, Preimplantation Genetic Diagnosis and Preimplantation Genetic Screening (PGD and PGS) and / or IVF with PGD are subject first to health plan benefits and limitations related to assisted reproductive technology (ART). If there is a health plan benefit for ART, determination (denial or approval) requires review by the Health Plan’s Medical Director.
F. Whole Exome Sequencing (WES) and Whole Genome Sequencing (WGS) for evaluation of fetal demise or recurrent pregnancy loss is considered experimental, investigational, and unproven and not medically necessary.
G. Uterine transplantation for treatment of absolute uterine factor infertility is considered experimental, investigational and unproven.
H. Intravaginal culture for treatment of infertility is considered experimental, investigational, and unproven.
I. The following tests and treatments (1 through 15 below) for recurrent pregnancy loss (RPL) will be considered experimental, investigational, and unproven to affect health /pregnancy outcomes:
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Aspirin, heparin, or low molecular weight heparin to treat unexplained recurrent pregnancy loss (RPL)
Cytokine testing
Intravenous immunoglobulin-glucocorticoids (IVIG)
Intralipid infusion. There are clinical trials in progress for RPL and recurrent implantation failure.
Paternal cell immunization
Sperm DNA fragmentation studies for infertility evaluation and/or recurrent pregnancy loss
Testing for peripheral blood or uterine natural killer cells
Third-party donor leukocytes
TORCH screening (group of blood tests including toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and HIV; may also include other infections)
Treatment of suppression of high levels of luteinizing hormone
Trophoblast membrane infusion
Use of steroids in treating miscarriage associated with antiphospholipid syndrome (aPL, APS)
Testing for Factor V Leiden or F2 Prothrombin, unless there are risk factors for thrombophilia (see MCG: Factor V Leiden Thrombophilia- F5 Gene) and Prothrombin Thrombophilia- F2 Gene.
Microarray testing of products of conception, unless the above Indications of Coverage A. 8. are met.
High-resolution peripheral karyotypic analysis
Documentation Required:
• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
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•
Medical record information (including continued need/use if applicable) and medical
necessity. Office notes, Procedure reports
•
Correct coding for the item/service that meets all the coding guidelines.
Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.
Infertility and Recurrent Pregnancy Loss Testing and Treatment are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.
State mandates, laws or benchmark supersede this medical guideline.
Approved by the Medical Director
Guideline Review History:
Implemented 07/15/15, 10/01/16, 10/01/17, 10/01/18, 10/01/19, 12/01/20, 07/01/21, 09/01/21, 7/01/22, 12/01/23, 07/01/24, 03/01/26 Medical Guideline Committee Approval 06/13/14, 06/12/15, 06/03/16, 06/16/17, 06/15/18, 04/26/19, 06/18/20, 06/24/21, 06/23/22, 06/29/23, 06/27/24, Q4 2025 Reviewed
06/13/14, 06/12/15, 06/03/16, 06/16/17, 06/15/18, 04/26/19,
06/18/20, 06/24/21, 08/26/21, 06/23/22, 06/29/23, 06/27/24, Q4
2025
Revised
06/12/15, 06/03/16, 06/16/17, 06/15/18, 10/01/19, 06/18/20,
08/26/21
Developed
Note: For review/revision history prior to 2014 see previous Medical Guideline
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Codes: The following codes may or may not be covered based on the member’s
certificate. This is strictly a list of potential infertility and/or recurrent pregnancy loss
related codes.
Code
Description
S4011
IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED
TO IDENTIFICATION AND INCULBATION OF MATURE
OOCYTES, FERTILIZATION WITH SPERM, INCUBATION OF
EMBRYO(S), AND SUBSEQUENT VISUALIZATION FOR
DETERMINATION
OF
DEVELOPMENT
(FERTILITY
SERVICES NOT COVERED)
S4013
COMPLETE
CYCLE,
GAMETE
INTRAFALLOPIAN
TRANSFER (GIFT), CASE RATE (FERTILITY SERVICES NOT
COVERED)
S4014
COMPLETE CYCLE, ZYGOTE INTRAFALLOPIAN TRANSFER
(ZIFT), CASE RATE (FERTILITY SERVICES NOT COVERED)
S4015
COMPLETE IN VITRO FERTILIZATION CYCLE, NOT
OTHERWISE
SPECIFICED,
CASE
RATE
(FERTILITY
SERVICES NOT COVERED)
S4016
FROZEN IN VITRO FERTILIZATION CYCLE, CASE RATE
(FERTILITY SERVICES NOT COVERED)
S4017
INCOMPLETE CYCLE, TREATMENT CANCELLED PRIOR TO
STIMULATION, CASE RATE (FERTILITY SERVICES NOT
COVERED)
S4018
FROZEN EMBRYO TRANSFER PROCEDURE CANCELLED
BEFORE ASPIRATION, CASE RATE (FERTILITY SERVICES
NOT COVERED)
S4020
IN VITRO FERTILIZATION PROCEDURE CANCELLED
BEFORE ASPIRATION, CASE RATE (FERTILITY SERVICES
NOT COVERED)
S4021
IN VITRO FERTILIZATION PROCEDURE CANCELLED
AFTER ASPIRATION, CASE RATE (FERTILITY SERVICES
NOT COVERED)
S4022
ASSISTED
OOCYTE
FERTILIZATION,
CASE
RATE
(FERTILITY SERVICES NOT COVERED)
S4023
DONOR EGG CYCLE, INCOMPLETE, CASE RATE (FERTILITY
SERVICES NOT COVERED)
S4024
AIR POLYMER TYPE A INTRAUTERINE FOAM PER STUDY
DOSE
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S4025 DONOR SERVICES FOR IN VITRO FERTILIZATION (SPERM OR EMBRYO), CASE RATE (FERTILITY SERVICES NOT COVERED) S4026 PROCUREMENT OF DONOR SPERM FROM SPERM BANK (FERTILITY SERVICES NOT COVERED) S4027 STORAGE OF PREVIOUSLY FROZEN EMBRYOS (FERTILITY SERVICES NOT COVERED) S4028 MICROSURGICAL EPIDIDYMAL SPERM ASPIRATION (MESA) (FERTILITY SERVICES NOT COVERED) S4030 SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES; INITIAL VISIT (FERTILITY SERVICES NOT COVERED) S4031 SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES, SUBSEQUENT VISIT (FERTILITY SERVICES NOT COVERED) S4035 STIMULATED INTRAUTERINE INSEMINATION (IUI), CASE RATE (FERTILITY SERVICES NOT COVERED) S4037 CRYOPRESERVED EMBRYO TRANSFER, CASE RATE (FERTILITY SERVICES NOT COVERED) S4040 MONITORING AND STORAGE OF CRYOPRESERVED EMBRYOS, PER 30 DAYS (FERTILITY SERVICES NOT COVERED) S4042 MANAGEMENT OF OVULATION INDUCTION (INTERPRETATION OF DIAGNOSTIC TESTS AND STUDIES, NONFACE-TO-FACE MEDICAL MANAGEMENT OF THE PATIENT), PER CYCLE 55870 ELECTROEJACULATION 58100 ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE) 58321 ARTIFICIAL INSEMINATION; INTRA-CERVICAL (FERTILITY SERVICES NOT COVERED) 58322 ARTIFICIAL INSERMINATION; INTRA-UTERINE (FERTILITY SERVICES NOT COVERED) 58323 SPERM WASHING FOR ARTIFICIAL INSEMINATION (FERTILITY SERVICES NOT COVERED) 58340 CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION
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SONOHYSTEROGRAPHY
(SIS)
OR
HYSTEROSALPINGOGRAPHY
58345
TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE
CATHETER FOR DIAGNOSIS AND/OR RE-ESTABLISHING
PATENCY
(ANY
METHOD),
WITH
OR
WITHOUT
HYSTEROSALPINGOGRAPHY
58350
CHROMOTUBATION
OF
OVIDUCT,
INCLUDING
MATERIALS
58920
WEDGE
RESECTION
OR
BISECTION
OF
OVARY,
UNILATERAL OR BILATERAL
58970
FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY
METHOD (FERTILITY SERVICES NOT COVERED)
58974
EMBRYO
TRANSFER,
INTRAUTERINE
(FERTILITY
SERVICES NOT COVERED)
58976
GAMETE,
ZYGOTE,
OR
EMBRYO
INTRAFALLOPIAN
TRANSFER, ANY METHOD (FERTILITY SERVICES NOT
COVERED)
81228
CYTOGENOMIC
(GENOME-WIDE)
ANALYSIS
FOR
CONSTITUTIONAL
CHROMOSOMAL
ABNORMALITIES;
INTERROGATION OF GENOMIC REGIONS FOR COPY
NUMBER
VARIANTS,
COMPARATIVE
GENOMIC
HYBRIDIZATION [CGH] MICROARRAY ANALYSIS
81229
CYTOGENOMIC
(GENOME-WIDE)
ANALYSIS
FOR
CONSTITUTIONAL
CHROMOSOMAL
ABNORMALITIES;
INTERROGATION OF GENOMIC REGIONS FOR COPY
NUMBER AND SINGLE NUCLEOTIDE POLYMORPHISM
(SNP)
VARIANTS,
COMPARATIVE
GENOMIC
HYBRIDIZATION (CGH) MICROARRAY ANALYSIS
81265
COMPARATIVE
ANALYSIS
USING
SHORT
TANDEM
REPEAT (STR) MARKERS; PATIENT AND COMPARATIVE
SPECIMEN (E.G.,
PRE-TRANSPLANT RECIPIENT AND
DONOR GERMLINE TESTING, POST-TRANSPLANT NON-
HEMATOPOIETIC RECIPIENT GERMLINE [E.G., BUCCAL
SWAB OR OTHER GERMLINE TISSUE SAMPLE] AND
DONOR
TESTING,
TWIN
ZYGOSITY
TESTING,
OR
MATERNAL CELL CONTAMINATION OF FETAL CELLS
88235
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS;
AMNIOTIC FLUID OR CHORIONIC VILLUS CELLS
88289
CHROMOSOME
ANALYSIS;
ADDITIONAL
HIGH
RESOLUTION STUDY
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89250 CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS (FERTILITY SERVICES NOT COVERED) 89251 CULTURE OF OOCYTE9S)/EMBRYO(S), LESS THAN 4 DAYS; WITH CO-CULTURE OF OOCYTE(S)/EMBRYOS (FERTILITY SERVICES NOT COVERED) 89253 ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) (FERTILITY SERVICES NOT COVERED) 89254 OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID (FERTILITY SERVICES NOT COVERED) 89255 PREPARATION OF EMBRYO FOR TRANSFER (ANY METHOD) (FERTILITY SERVICES NOT COVERED) 89257 SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL FLUID) (FERTILITY SERVICES NOT COVERED) 89258 CRYOPRESERVATION; EMBRYO(S) (FERTILITY SERVICES NOT COVERED) 89259 CRYOPRESERVATION; SPERM (FERTILITY SERVICES NOT COVERED) 89260 SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH AND SWIM-UP) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS (FERTILITY SERVICES NOT COVERED) 89261 SPERM ISOLATION; COMPLEX PREP (EG, PERCOLL GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS 89264 SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR CRYOPRESERVED (FERTILITY SERVICES NOT COVERED) 89268 INSEMINATION OF OOCYTES (FERTILITY SERVICES NOT COVERED) 89272 EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7 DAYS (FERTILITY SERVICES NOT COVERED) 89280 ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; LESS THAN OR EQUAL TO 10 OOCYTES (FERTILITY SERVICES NOT COVERED) 89281 ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; GREATER THAN 10 OOCYTES (FERTILITY SERVICES NOT COVERED) 89290 BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE- IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR
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EQUAL TO 5 EMBRYOS (FERTILITY SERVICES NOT COVERED) 89291 BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE- IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN 5 EMBRYOS (FERTILITY SERVICES NOT COVERED) 89300 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SEPRM INCLUDING HUHNER TEST (POST COITAL) 89310 SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) 89320 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY AND DIFFERENTIAL 89321 SEMEN ANALYSIS; SPERM PRESENCE AND MOTILITY OF SPERM IF PERFORMED 89322 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL USING STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) 89325 SPERM ANTIBODIES 89329 SPERM EVALUATION; HAMSTER PENETRATION TEST 89330 SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR WITHOUT SPINNBARKEIT TEST 89331 SPERM EVALUATION; FOR RETROGRADE EJACULATION, URINE (SPERM CONCENTRATION, MOTILITY, AND MORPHOLOGY, AS INDICATED) 89335 CRYOPRESERVATION, REPRODUCTIVE TISSUE, TESTICULAR (FERTILITY SERVICES NOT COVERED) 89337 CRYOPRESERVATION, MATURE OOCYTE(S) 89342 STORAGE (PER YEAR); EMBRYO(S) (FERTILITY SERVICES NOT COVERED) 89343 STORAGE (PER YEAR); SPERM/SEMEN (FERTILITY SERVICES NOT COVERED) 89344 STORAGE (PER YEAR); REPRODUCTIVE TISSUE, TESTICULAR/OVARIAN (FERTILITY SERVICES NOT COVERED) 89346 STORAGE (PER YEAR); OOCYTE(S) (FERTILITY SERVICES NOT COVERED) 89352 THAWING OF CRYOPRESERVED; EMBRYO(S) (FERTILITY SERVICES NOT COVERED)
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89353 THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH ALIQUOT (FERTILITY SERVICES NOT COVERED) 89354 THAWING OF CRYOPRESERVED; REPRODUCTIVE TISSUE, TESTICULAR/OVARIAN (FERTILITY SERVICES NOT COVERED) 89356 THAWING OF CRYOPRESERVED; OOCYTES, EACH ALIQUOT (FERTILITY SERVICES NOT COVERED) 89398 UNLISTED REPRODUCTIVE MEDICINE LABORATORY PROCEDURE G0027 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM EXCLUDING HUHNER
Associated Codes 49320 LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) 58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) 58560 HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD) 58672 LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY 58673 LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY) 58700 SALPINGECTOMY, COMPLETE OR PARITAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) 58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) 58760 FIMBRIOPLASTY 58770 SALPINGOSTOMY (SALPINGONEOSTOMY) 58920 WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR BILATERAL 58970 FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD (FERTILITY SERVICES NOT COVERED) 58974 EMBRYO TRANSFER, INTRAUTERINE (FERTILITY SERVICES NOT COVERED) 58976 GAMETE, ZYGOTE, OR EMBRYO INTRAFALLOPIAN TRANSFER, ANY METHOD (FERTILITY SERVICES NOT COVERED) 74740 HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
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74742 TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 76856 ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE 76857 ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES) 76948 ULTRASOUND GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION (FERTILITY SERVICES NOT COVERED) 81224 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG, CYSTIC FIBROSIS) GENE ANALYSIS; INTRON 8 POLY-T ANALYSIS (EG, MALE INFERTILITY) 82397 CHEMILUMINESCENT ASSAY 82670 ESTRADIOL; TOTAL 83001 GONADOTROPHIN; FOLLICLE STIMULATING HORMONE (FSH) 83002 GONADOTROPHIN; LUTEINIZING HORMONE (LH) 83498 HYDROXYPROGESTERONE, 17-D 84144 PROGESTERONE 84146 PROLACTIN 84402 TESTOSTERONE; FREE 84403 TESTOSTERONE; TOTAL 84443 THYROID STIMULATING HORMONE (TSH) 84830 OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR HUMAN LUTEINIZING HORMONE 87109 CULTURE, MYCOPLASMA, ANY SOURCE 87118 CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE 88182 FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS 88184 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER 88185 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY;
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EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER) 88248 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROME; BASELINE BREAKAGE, SCORE 50-100 CELLS, COUNT 20 CELLS, 2 KARYOTYPES (EG, FOR ATAXIA TELANGIECTASIA, FANCONI ANEMIA, FRAGILE X) 88261 CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING 88262 CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH BANDING 88263 CHROMOSOME ANALYSIS; COUNT 45 CELLS FOR MOSAICISM, 2 KARYOTYPES, WITH BANDING 88273 MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, ANALYZE 10-30 CELLS (EG, FOR MICRODELETIONS) 88280 CHROMSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY 88283 CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING TECHNIQUE (EG, NOR, C-BANDING) 88285 CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY 0252U FETAL ANEUOPLOIDY SHORT TANDEMAC REPEAT COMPARATIVE ANALYSIS, FETAL DNA FROM PRODUCTS OF CONCEPTION, REPORTED AS NORMAL (EUPLOIDY), MONOSOMY, TRISOMY, OR PARTIAL DELETION/DUPLICATIONS, MOSAICISM, AND SEGMENTAL ANEUOPLOIDY (NEW CODE AS OF 7/1/21) 0253U REPRODUCTIVE MEDICINE (ENDOMETRIAL RECEPTIVITY ANALYSIS), RNA GENE EXPRESSION PROFILE, 238 GENES BY NEXT-GENERATION SEQUENCING, ENDOMETRIAL TISSUE, PREDICTIVE ALGORITHM REPORTED AS ENDOMETRIAL WINDOW OF IMPLANTATION (EG, PRE- RECEPTIVE, RECEPTIVE, POST-RECEPTIVE) (NEW CODE AS OF 7/1/21) 0254U REPRODUCTIVE MEDICINE (PREIMPLANTATION GENETIC ASSESSMENT) ANALYSIS OF 24 CHROMOSOMES USING EMBRYONIC DNA GENOMIC SEQUENCE ANALYSIS FOR ANEUOPLOIDY, AND A MITOCHONDRIAL DNA SCORE IN EUPLOID EMBRYOS, RESULTS REPORTED AS NORMAL (EUPLOIDY), MONOSOMY, TRISOMY, OR PARTIAL DELETION/DUPLICATIONS, MOSAICISM, AND
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SEGMENTAL ANEUPLOIDY, PER EMBRYO TESTED (NEW CODE AS OF 7/1/21) 0568T INTRODUCTION OF MIXTURE OF SALINE AND AIR FOR SONOSALPINGOGRAPHY TO CONFIRM OCCLUSION OF FALLOPIAN TUBES, TRANSCERVICAL APPROACH, INCLUDING TRANSVAGINAL ULTRASOUND AND PELVIC ULTRASOUND 0664T DONOR HYSTERECTOMY (INCLUDING COLD PRESERVATION); OPEN, FROM CADAVER DONOR 0665T DONOR HYSTERECTOMY (INCLUDING COLD PRESERVATION); OPEN, FROM LIVING DONOR 0666T DONOR HYSTERECTOMY (INCLUDING COLD PRESERVATION); LAPAROSCOPIC OR ROBOTIC, FROM LIVING DONOR 0667T DONOR HYSTERECTOMY (INCLUDING COLD PRESERVATION); RECIPIENT UTERUS ALLOGRAFT TRANSPLANTATION FROM CADAVER OR LIVING DONOR 0668T BACKBENCH STANDARD PREPARATION OF CADVER OR LIVING DONOR UTERINE ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES AND PREPARATION OF UTERINE VEIN(S) AND UTERINE ARTERY(IES), AS NECESSARY 0669T BACKBECK RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION, VENOUS ANASTAMOSIS, EACH 0670T BACKBECK RECONSTRUCTION OF CADAVER OR LIVING DONOR UTERUS ALLOGRAFT PRIOR TO TRANSPLANTATION, ARTERIAL ANASTOMOSIS, EACH
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