Infertility Treatment Form

1 Infertility Treatment - Medical Policy Updated Revision Effective: April 1, 2026 Policy Number: UM185POL Approval Date: Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy) Description Infertility Services Massachusetts mandates certain health insurance coverage of non-experimental infertility procedures recognized by the American Society for Reproductive Medicine (ASRM) or the American College of Obstetrics and Gynecology (ACOG). In accordance with these mandates, HNE will provide infertility benefits to medically infertile members with the goal of restoring normal reproductive capacity. Coverage for infertility services is available to members who meet individual plan limitations, medical necessity and eligibility criteria outlined in this protocol.
Reasonable and necessary services associated with treatment for infertility are covered under Medicare. Infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a person who normally is expected to be fertile to seek medical consultation and treatment. The following criteria apply. Definitions/Descriptions Infertility is defined as ONE of the following: • The inability of opposite-sex partners under the age of 35 to achieve conception after at least one year of unprotected intercourse • The inability of opposite-sex partners to achieve conception after six months of unprotected intercourse when the biological female partner trying to conceive is age 35 or older • The inability of a biological female under age 35 without an opposite sex partner, to achieve conception after at least six trials of medically supervised artificial insemination • The inability of a biological female age 35 and older, without an opposite-sex partner, to achieve conception after at least three trials of medically supervised artificial insemination. Gender Descriptions: The term biological female used in this policy refers to members with two X chromosomes (or no Y chromosome) and includes members with gender identities other than female. The term biological male used in this policy refers to members with XY chromosomes and includes members with gender identities other 12/29/2025

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than male. In this policy, the terms biological female and biological male are used to clarify the reproductive capacity of the member and are not meant to exclude members with other gender identities/expressions.

In-network providers should submit authorization requests utilizing HNE’s Infertility Treatment Prior Approval Request Form. Forms can be found on HNE’s Provider Site: https://healthnewengland.org/Portals/_default/Shared%20Documents/providers/InfertilityPAdoc.pdf

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicare:
Refer to criteria under the Policy section in this medical policy. Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for Infertility Treatment.

Policy

Service-Specific Criteria:

SERVICE
CRITERIA
Intrauterine Insemination (IUI)

In addition to the general criteria listed above, IUI is considered medically necessary when bullets A, B, and C below are met.

A. Results of a uterine cavity evaluation (sonohysterogram, hysterosalpingogram, or hysteroscopy) within the past 2 years confirming the presence of ALL the following:
• At least one patent Fallopian tube
• Normal ipsilateral ovary
• Normal endometrial cavity
B. Documentation of spontaneous ovulation C. For couples with a male genetic disorder who opt to use donor sperm after IVF/ICSI/PGT if the female member meets IUI criteria. (Coverage for IUI is limited to 6 cycles with documented ovulation.) In the absence of an intervening live birth, subsequent IUI cycles are not authorized for members who have already undergone IVF if further IVF cycles do not meet HNE’s IVF criteria.

IUI is considered not medically necessary in the following circumstances: • Bilateral tubal factor infertility • Recurrent pregnancy loss-defined by 2 or more failed pregnancies (absent an ovulatory disorder) • Severe endometriosis

Assisted Hatching (AH)

In addition to the general criteria listed above, AH is considered medically necessary when it is part of IVF or FET and ANY ONE of the following bullets are met.

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SERVICE
CRITERIA
A. Women with a history of 2 or more embryo transfers without a pregnancy
B. History of a prior pregnancy as a result of IVF and AH
C. Planned transfer of a frozen-thawed embryo D. Thick Zonae in prior or current IVF. AH is considered not medically necessary in the following circumstances: • If preimplantation genetic diagnosis (PGD) is being performed, as this process includes opening the zona pellucida.

Cryopreservation of Eggs and/or Embryos

No more than 1 cycle of IVF will be covered for members who will undergo treatment that is expected to render them infertile.

Cryopreservation of eggs and/or embryos is considered medically necessary when bullets A or B below are met.

A. For women in active (authorized) infertility treatment: • HNE covers retrieval, cryopreservation, and up to one year of storage, of any embryos. The storage is for a member in an active fertility cycle when there is an unexpected lack of sperm for fertilization o Meets the general criteria listed above
o Requests for authorization of a Thaw Cycle (using frozen eggs or embryos) must meet General Eligibility Criteria (above) at the time of the request.
o Cryopreserved embryos (or eggs) must be used before additional (fresh) IVF cycles.
B. For women who are not in active infertility treatment:
• The member is not required to meet HNE’s General Eligibility Criteria for Infertility Services. • HNE covers retrieval, cryopreservation, and storage (up to five years) of eggs or embryos when documentation confirms a female member who is not in active treatment for infertility will be undergoing medical treatment (e.g., chemotherapy, radiation therapy) or other treatment that is expected to render them permanently infertile (excluding voluntary sterilization) C. For members not in active infertility treatment, who are requesting fertilization of eggs and cryopreservation of embryos:
• Results of ovarian testing, and the male partner’s semen analysis, must be submitted to assess the likelihood of embryo creation.

Cryopreservation and Sperm Collection

In addition to the general criteria listed above, sperm collection, cryopreservation and up to one year of storage is considered medically necessary when ANY ONE of the bullets below are met.

A. There is a need for frozen back-up sperm because of unreliable ability to produce adequate or useful sperm on the day of ovulation or egg retrieval after ovulation. B. Sperm was recovered through MESA or TESE for members in active infertility treatment.

NOTE: If the criteria above is met and documentation confirms that the member is undergoing medical treatment (e.g., cancer treatment) or

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SERVICE
CRITERIA
other treatment that is expected to render them infertile, sperm storage will be approved for up to five years.

Cryopreservation of Eggs or Sperm
for Gender Affirmation Treatment

In addition to the general criteria listed above, cryopreservation of eggs or sperm (including retrieval and up to five years of storage or five years from the member’s 18 birthday) is considered medically necessary when bullets A, B, and C below are met.

A. Documentation confirms a member with Gender Dysphoria will be undergoing covered Gender Affirming treatment that is likely to result in infertility.
B. Adequate sperm or egg evaluation would be needed to be eligible. C. Documentation must confirm that member and provider(s) have discussed the impact of Gender Affirmation treatment on fertility and family planning.

NOTES:
• Cryopreservation is limited to one cycle only. • There is no coverage for costs associated with any form of Surrogacy including gestational carriers

Donor Eggs (Donor Oocyte)

In addition to the general criteria listed above, donor eggs are considered medically necessary for women under age 44 years when bullet A, B, C, or D below are met.

A. Donor egg is covered for medical illness which causes a natural loss of egg quantity and/or quality
B. Congenital or surgical absence of the ovaries C. Premature ovarian failure or premature ovarian insufficiency (i.e., FSH ≥15) in women under age 40 years D. Inadequate ovarian response (i.e., at least two IVF treatments cycles where <6 eggs were retrieved with maximum ovarian stimulation).

Donor eggs are considered not medically necessary in the following circumstances: • For women aged 44 or greater as they are experiencing an age- related decline in fertility that is normal and expected, and not consistent with disease process. While these individuals may require donor egg/embryo to achieve a positive birth outcome, the need is secondary to an age-related decline in fertility that is normal and expected

NOTES: • Medications for the member recipient will only be covered if the member has an HNE pharmacy benefit. Medication for the anonymous or designated donor in an approved cycle will not be covered. • After proceeding to a donor egg cycle, further IVF cycles using the member’s eggs are not authorized

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SERVICE
CRITERIA
Donor Sperm One vial per IVF/IUI cycle

In addition to the general criteria listed above, donor sperm from an accredited sperm bank is considered medically necessary when:

A. Biological male has a diagnosis of balanced reciprocal translocation or Robertsonian translocation based on karyotype screening of sperm and partner has a diagnosis of recurrent pregnancy loss OR

Exception to the criteria of meeting the diagnosis of infertility: A. Donor sperm is considered medically necessary if the member meets the criteria for Preimplantation Genetic Diagnosis Testing

NOTES: Donor sperm is not covered for biological females without a biological male partner.

Frozen Embryo Transfer (FET)

In addition to the general criteria listed above, FET is considered medically necessary when bullets A or B below are met.

A. There is a normal uterine cavity evaluation within two years.
B. If there has been a pregnancy or pregnancy loss, there is a normal uterine cavity evaluation after.

NOTES: Frozen embryos must be used prior to authorization for additional fresh cycles.

Gamete-Intra-Fallopian Transfer (GIFT)

In addition to the general criteria listed above, GIFT is considered medically necessary when bullets A and B below are met.

A. Member has one normal patent fallopian tube B. Member also meets IVF criteria Intra-Cytoplasmic Sperm Injection (ICSI)

In addition to the general criteria listed above, ICSI is considered medically necessary when ANY ONE of the criteria below are met.

A. Less than 50% fertilization (for mature eggs) on previous IVF attempt B. If using sperm that was retrieved via Microsurgical Epididymal Sperm Aspiration (MESA) or Testicular Sperm Extraction (TESE) C. When cryopreserved eggs are used

ICSI is considered not medically necessary in the following circumstances: A. When using donor eggs for criteria A, B, or C above. B. When done solely to perform preimplantation genetic diagnosis testing.

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SERVICE
CRITERIA
In-Vitro Fertilization (IVF)

In addition to the general criteria listed above, IVF is considered medically necessary when ANY ONE of the criteria below are met.

Clinical Criteria ANY ONE of the criteria below must be met: A. Documented history of three (3) failed medicated IUI cycles, when IUI criteria have been met B. The female member has ANY of the following:
• Bilateral Fallopian tube absence (excluding prior elective sterilization) or bilateral Fallopian tube obstruction due to prior tubal disease.
• Severe endometriosis.
• Recurrent pregnancy loss-defined by 2 or more failed pregnancies (absent an ovulatory disorder) C. The male member has severe male factor infertility, as evidenced by at least 2 processed/unprocessed semen analyses showing ≤10 million total motile sperm D. At least two (2) unprocessed semen analyses show ≤ 2% strict Kruger normal forms. E. Member is in an approved current IUI cycle that has resulted in an Estradiol level of ≥800 pg/ml and production of at least 3 follicles >13 mm in size.

IVF is considered not medically necessary in the following circumstances: A. When the woman is age ≥44. B. IVF cycles using a member’s own eggs are considered not medically necessary for members who have undergone previous donor egg cycles.

NOTES: • Members of any age will be required to follow ASRM (American Society for Reproductive Medicine) guidelines for embryo transfers. • An IVF cycle will be approved one cycle at a time to determine that the probability of a live birth remains using one’s own eggs. If the ART cycle does not demonstrate the attainment of at least one (1) embryo suitable for transfer an additional cycle may be considered when there is a significant change in the treatment protocol such as a change in dosage, a change in protocol or a change in the clinical presentation. • The chances of a live birth after greater than 6 consecutive unsuccessful IVF cycles in women age 40 and over is typically less than 5%. • For women ages ≥44: Fertility is not considered a natural state due to age-related decline in oocyte number and quality at or beyond age 44 regardless of hormonal testing. • Cryopreserved embryos (or oocytes) must be used prior to an additional fresh cycle.

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SERVICE
CRITERIA
Microsurgical Epididymal Sperm
Aspiration (MESA)

In addition to the general criteria listed above, MESA is considered medically necessary when:

A. There is a congenital absence or congenital obstruction of the vas deferens. This does not include obstruction resulting from prior sterilization or sterilization reversal procedures

Testicular Sperm Extraction (TESE)
In addition to the general criteria listed above, TESE is considered medically necessary when:

A. There is a documented nonobstructive azoospermia, or spinal cord injury resulting in inability to ejaculate.

Zygote Intra-Fallopian Transfer (ZIFT)

In addition to the general criteria listed above, ZIFT is considered medically necessary when:

A. The member has one normal patent Fallopian tube and meets IVF criteria above.

III. Individual Plan Limitation

Self-Funded Group members: Self-funded plans are not required to provide mandated infertility services. If a self-funded group offers infertility coverage, benefits will be provided to all members subject to the defined plan limitations, as outlined in the group’s Summary Plan Description, which may reference this protocol.

IV. What is Not Covered?

A. HNE does not cover Infertility Services when criteria above are not met.
B. In addition, HNE does not cover Infertility services for ANY of the following:

1. Members without HNE Infertility benefits
2. Members who are not medically infertile unless the member meets other HNE criteria (e.g., PGD, sperm/egg banking and storage for a member who is undergoing medical treatment that is likely to result in infertility)
3. Individuals who are not members (including partners, dependents, or other third parties), or services in which the member is not treated, or is not the intended recipient of the infertility services
4. Infertility services (including but not limited to consultations, labs, radiology studies, infertility drugs, ART cycles, and other services to assess and/or treat infertility in a member or a member’s partner) requested as a result of a prior voluntary sterilization or unsuccessful sterilization reversal procedure unless there is documentation that criteria (above) are met
5. Infertility services requested to treat effects that are due to natural aging, or for women who are menopausal. Any elevation in FSH level (>15) in members ≥40 years of age is considered infertility as a natural state and therefore infertility services are not covered.
6. Donor sperm is not covered:
   a. In the absence of documented male factor infertility, or for genetic sperm defects in the male partner when the male partner is not an HNE member

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b. In the absence of a male partner c. For biological females without a biological male partner d. When the male partner has undergone vasectomy reversal and fails to meet the medical necessity criteria for infertility services for males with prior vasectomy with reversal

7. Sperm storage/banking for males requesting this service for convenience or “back-up” for a fresh specimen
8. Infertility services in cases in which normal embryos have been or will be discarded because of gender selection
9. Cryopreservation of embryos or eggs for reciprocal IVF is not covered
10. Any Advanced Reproductive Technology requested solely for PGD (e.g., IVF, ICSI) when PGD is not a covered benefit, or PGD criteria (above) are not met
11. Treatments requested solely for the convenience, lifestyle, personal or religious preference of the member in the absence of medical necessity
12. Treatment to reverse voluntary sterilization, or MESA/TESE, for a member who has undergone prior sterilization
13. Supplies that may be purchased without a physician’s written order (e.g., ovulation test kits)
14. Services related to achieving pregnancy through a surrogate or gestational carrier
15. Implantation or other services provided to a gestational carrier, including but not limited to transfer, impending pregnancy costs or cryopreservation of embryos, whether or not the gestational carrier is an HNE member
16. Use of donor egg with gestational carrier even when the surrogate is a member of the health plan
17. Charges for the storage of eggs, sperm or embryos that remain in storage after the completion of an approved series of infertility cycles, or more than 1 year after the cryopreservation (whichever is shorter)
18. Fees related to the payment of the egg donor; donor identification, legal services, or selection, purchase and transportation of frozen donor egg/embryos, including the purchase of donated frozen eggs or donated frozen embryos. (This exclusion does not include the charges related to the medical procedure of removing an egg for the purpose of donation when the recipient is a member of the Plan.)
19. Infertility services when clinical documentation confirms an individual or couple is using illicit substances or abusing substances known to negatively interfere with fertility or fetal development (e.g., cigarettes, marijuana, opiates, cocaine, or alcohol)
20. Shipping costs for donor egg or donor sperm
21. Endometrial receptivity testing
22. Infertility services for women who are not Rubella immune
23. Voluntary male sterilization (chemical or procedural) ends coverage for IVF, ICSI and donor sperm based on male factor or unexplained infertility. Any abnormal semen analysis post a reversal ends eligibility for coverage of infertility services.
24. Home inseminations
25. Uterine transplants

26. Assisted reproductive technology treatments are not covered for those with a very poor prognosis (<5% chance of achieving a live birth).

    Clinical Guidelines

    I. Benefit Coverage

    A. HNE Infertility benefits include coverage for non-experimental services that are medically necessary to

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diagnose and treat medical infertility for members with uteri/eggs when such treatment is likely to result in viable offspring. Covered services include, but are not limited to:

1. Specialist consultation
2. Diagnostic services (e.g., lab work, hysterosalpingogram, laparoscopy, and ultrasound) that are medically necessary to assess infertility
3. Assisted Reproductive Technology (ART) services including: • Artificial Insemination (AI) Intrauterine Insemination (IUI)
   • Assisted Hatching
   • Collection, storage cryopreservation and banking of sperm, eggs (oocytes), or embryos • Donor eggs
   • Donor sperm
   • Embryo Transfer/Frozen Embryo Transfer (FET)
   • Gamete-Intra-Fallopian Transfer (GIFT)
   • Intra-Cytoplasmic Sperm Injection (ICSI)
   • In-Vitro Fertilization (IVF) including conversion from IUI to an IVF cycle
   • Microsurgical Epididymal Sperm Aspiration (MESA)
   • Pre-implantation Genetic Diagnosis: See HNE’s Medical Review Criteria for Preimplantation Genetic Diagnosis (PGD) for information regarding coverage and authorization requirements for PGD.
   • Testicular Sperm Extraction (TESE)
   • Zygote Intra-Fallopian Transfer (ZIFT)

4. Prescription fertility drugs that are FDA approved that can be self-administered (e.g., ovulatory injections including HCG) are covered only for members with HNE prescription drug coverage who are in an active, authorized cycle of infertility treatment.

   II. Clinical Guidelines

   A. Coverage for required infertility benefits will not be limited arbitrarily but may be limited according to reasonable consideration of the individual member’s medical history, hormone levels and age, medical necessity guidelines, provider standards and protocols, and legal requirements or limitations. Unless ineligible for reasons unrelated to this provision and based upon the recommendation of the patient’s clinician specialist, members who meet the residency requirements, the above definition of infertility, and the following criteria (where relevant) are eligible for ART services. B. For a member with uteri/eggs to be considered for cycle initiation of a covered ART service:

5. The member must meet the definition of medical infertility (as defined above) and infertility may not be the result of a previous sterilization or unsuccessful reversal.
6. Treatment is likely (i.e., with greater than 5% probability) to result in viable offspring.
7. Documentation (i.e., clinical history including: diagnosis, menopausal status, response to and outcomes of previous infertility treatment) confirms that infertility treatment using the female partner’s eggs will result in a live birth.
   a. For biological women with a diagnosis of premature ovarian failure (POF), premature diminished ovarian reserve, or premature menopause, documentation must confirm that, absent such a diagnosis, the member would be an individual in whom fertility would naturally be expected.
   C. Evaluation Requirements
8. Baseline hormonal blood work (including FSH and Estradiol) done within the past year

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2. Rubella testing - all non-immune members must be vaccinated and wait 30 days before requesting infertility treatment.
3. TSH (thyroid stimulating hormone) must be done yearly.
4. HSG/tubal patency eval (unless going directly to IVF)
5. For members going directly to IVF: a. Uterine Cavity eval: HSG/hysteroscopy, Sonohysterogram, 3D ultrasound or hysterosalpingo contrast sonography (HyCoSy) b. Testing must be done every two years or after a pregnancy loss
6. Semen analysis done yearly
7. Urine or serum cotinine levels must be obtained within the month of the requested service for all members and their partners who acknowledged smoking/vaping within the past year. Non-smoking members with an initial negative cotinine level test are not required to have repeat or ongoing cotinine tests. D. Testing of the Biological Female
8. Premature ovarian insufficiency occurs below age 40 and is defined as: a. A day 3 FSH >15 mIU/ml, OR b. A day 3 estradiol >100 pg/ml and no medical reason is documented (i.e. ovarian cyst)
9. Members <40 years old a. Members with premature ovarian insufficiency may qualify for IVF treatment, or may qualify for donor egg/embryo b. A repeat FSH/estradiol is not needed if a member <39 years of age has already been diagnosed with premature ovarian insufficiency
10. Members who are ≥40 and <44 years old must meet ALL of the following criteria: a. Yearly clomiphene citrate challenge test (CCCT) b. If 6 months have elapsed since the CCCT, a basal FSH and estradiol are required prior to the next fresh IVF cycle. c. A new CCT or repeat FSH/estradiol is not required for FET’s from an approved IVF cycle.)
11. Lab values needed from CCT for IVF coverage (highest ever value) for age 40-44 a. All day 3 or day 10 FSH must be <15 mIU/ml b. All day 3 estradiol must be ≤100 pg/ml c. Day 10 estradiol >100 pg/ml
12. Alternate testing options only for those members not able to do CCCT: a. For members with a documented contraindication to clomiphene or ovulation disorder (i.e., PCOS, hypothalamic amenorrhea) a combination of tests would be accepted: i. Basal FSH, estradiol, and AMH done on the same day, AND ii. Antral follicle count (AFC) done within 1 month of labs iii. Lab values needed for infertility services coverage: a) AMH >1.0 NG/ML, and b) AFC >6, and c) Day 3 FSH <15 d) Day 3 estradiol ≤ 100 pg/ml
13. Biological women over age 40 with ANY history of Day 3 or Day 10 FSH >15 remain eligible for coverage of the transfer of frozen embryos created prior to the abnormal test finding but are not eligible for ANY further assisted reproduction treatments.
    E. Evaluation of the Biological Male:
14. Semen analysis must be done yearly.
15. Normal fertility threshold is defined as: semen volume 1.4 ml, , sperm total 39 million, 42% motility, and 4% normal morphology by Krüger classification, or morphology of 30% by WHO (based on World Health Organization 6th edition 2021).
16. Medical records for a member who was covered under a different insurer will be requested for review to determine male infertility status.

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4. Medical and reproductive history (including any substance use) must be submitted.
5. If the biological male has previously undergone vasectomy reversal, 2 post reversal semen analyses (6 months apart) showing ≥ 20 million total motile sperm AND ≥ 3% normal forms, AND
6. Member has a normal semen analysis 6 months prior to the infertility service request.
   F. Substance Use/Contraindications for Fertility Treatments
7. Tobacco / Electronic Cigarettes (Vaping) - Due to the toxic effects of tobacco/nicotine on female and male fertility and in pregnancy, both members of the couple must be non-smokers of traditional or electronic cigarettes and are not exposed to second hand smoke on a regular basis.
   a. No infertility services will be approved if cotinine is found in the member or the member’s partner.
   b. No infertility services will be approved if the member or member’s partner have smoked in the last 2 months.
   c. Urine or serum cotinine levels must be obtained within the month of the requested service, for all members and their partners who acknowledged smoking within the past year
8. Other Substances – Due to the known negative effects related to fertility and/or fetal development, if either member of a couple a. has an alcohol related disorder- due to known negative effects related to fertility and/or fetal development if either member of the couple has used alcohol within the past 6 months and need to maintain sobriety OR
   b. is consuming substances that are against medical advice OR c. is using illegal substances, such as marijuana, opiates, cocaine OR d. marijuana (medical or recreational), cannabinoid products (edibles, CDB oil, topicals, etc.) AND e. serum or urine drug screening results may be requested before infertility services are authorized. Positive results may result in a denial of the request.
9. Substance Use disorder (SUD):
   a. Members and partners in medication assisted therapy (MAT) programs must have been enrolled for 1 year, and receiving MAT with buprenorphine, buprenorphine/naloxone, methadone or naltrexone may be considered for infertility services. Documentation of continued participation in a program including monitoring and provision of cognitive behavioral therapy (CBT) is required.
   G. IVF
10. Results of prior IVF cycles must demonstrate an adequate response to each cycle (i.e., at least 3 follicles >12 mm diameter, and adequate embryo numbers and quality for transfer), and adequate fresh semen and post-wash semen parameters.
11. Documentation confirming the female member requesting IVF has undergone hysterosalpingogram, sonohystogram, or hysteroscopy (to establish uterine contours) within the past 2 years is required. a. Age-Specific Criteria b. For members <35 years of age c. With favorable prognosis (1st IVF cycle, previous IVF success, good quality embryos/excess embryos available for freezing), 1 blastocyst d. Others-≤2
12. For members age 35-37 a. With favorable prognosis-1 blastocyst b. Others-≤2
13. For members age 38-40 a. With favorable prognosis-≤2 blastocysts b. Others-≤3
14. For members age 41 and greater a. With favorable prognosis-≤3 b. All others-≤3
15. For members age 35 and greater, without male partners or exposure to sperm

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a. history of 3 failed medicated IUI cycles.

Coding Guidance

Code
Description
Auth Required HCPC Codes

S4015 Complete in vitro fertilization cycle, not otherwise specified, case rate Yes S4016 Frozen in vitro fertilization cycle, case rate Yes S4017 Incomplete cycle, treatment cancelled prior to stimulation, case rate Yes S4018 Frozen embryo transfer procedure cancelled before transfer, case rate Yes S4020 In vitro fertilization procedure cancelled before aspiration, case rate Yes S4021 In vitro fertilization procedure cancelled after aspiration, case rate Yes S4023 Donor egg cycle, incomplete, case rate Yes S4025 Donor services for in vitro fertilization (sperm or embryo), case rate Yes S4026 Procurement of donor sperm from sperm bank (to CPT codes) Yes S4028 Sperm aspiration from epididymis by means of microsurgery Yes CPT Codes

58323 Sperm washing for artificial insemination Yes 89253 Assisted embryo hatching, microtechniques (any method) Yes 89258 Cryopreservation; embryos Yes 89259 cyropreservation of sperm Yes 89344 Storage (per year); reproductive tissue, testicular/ovarian Yes 89346 Storage (per year); oocyte(s) Yes 89354 Thawing of cryopreserved; reproductive tissue, testicular/ovarian Not Covered 89356 Thawing of cryopreserved; oocytes, each aliquot Not Covered CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Act Providing a Medical Definition of Infertility: https://www.mass.gov/doc/21137pdf/download

Assisted Reproductive Technology (ART. (2019, April 9)
Content source: National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health

13 WHO laboratory manual for the Examination and processing of human semen, 5th edition. (2010).
Eisenberg, E., MD MPH, Brumbaugh, K., MPH CHES, Brown-Bryant, R., MS, & Warner, L., PhD. (2019, April 1). Wang, A., Santistevan, A., Hunter Cohn, K., Copperman, A., & Nulsen, J. (2017, August). Freeze-only versus fresh embryo transfer in a multicenter matched cohort study: Contribution of progesterone and maternal age to success rates.
Djurovic, M., Pekic, S., Petakov, M., Damjanovic, S., & Doknic, M. (204, June). Gonadotropin response to clomiphene and plasma leptin levels in weight recovered but amenorrhoeic patients with anorexia nervosa.
Mao C, Grimes, DA. The sperm penetration assay: can it discriminate between fertile and infertile men? Am J Obstet Gynecol 1988;159:279-86. Diagnostic evaluation of the infertile male: A Committee Opinion. ASRM Fertil Steril 2012;98:294-301. Borges, L., Morgante, G., Musacchio, M., Petraglia, F., & De Leo, V. (2007, June). New protocol of clomiphene citrate treatment in women with hypothalamic amenorrhea.
Guzick, D., Carson, S., Coutifaris, C., Overstreet, J., & Factor-Litvak, P. (1999, January 21). Efficacy of superovulation and intrauterine insemination in the treatment of infertility. National Cooperative Reproductive Medicine Network.
Martin, K., Hall, J., Adams, J., & Crowley, Jr, W. (1993, July). Comparison of exogenous gonadotropins and pulsatile gonadotropin-releasing hormone for induction of ovulation in hypogonadotropic amenorrhea.
Meczekalski, B., Katulski, K., Czyzyk, A., Podfiqurma-Stopa, A., & Maciejewska-Jeske, M. (2014, November). Functional hypothalamic amenorrhea and its influence on women's health. Medicare Benefit Policy Manual. Chapter 15- Covered medical and other health services. https://www.cms.gov/ Kasman, A. M., MD, Thoma, M. E., PhD, McLain, A. C., PhD, & Eisenberg, M. L., MD. (2018, May). Association between use of marijuana and time to pregnancy in men and women: Findings from the National Survey of Family Growth. American Society for Reproductive Medicine Committee Opinion No. 722: Marijuana Use During Pregnancy and Lactation. (2017, October). Practice Committee of the American Society for Reproductive Medicine and the Practice Committee for the Society for Assisted Reproductive Technologies (2021). Guidance on the limits to the number of embryos to transfer: a committee opinion
The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis Pai HD, Baid R, Palshetkar NP, Pai A, Pai RD, Palshetkar R. Oocyte Cryopreservation - Current Scenario and Future Perspectives: A Narrative Review. J Hum Reprod Sci. 2021 Oct-Dec;14(4):340-349. doi: 10.4103/jhrs.jhrs17321. Epub 2021 Dec

31. PMID: 35197678; PMCID: PMC8812387. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8812387/ Policy Implementation

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Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 10/2002 Original policy date 12/2023 Policy moved to new template Biological female and male clarified No significant changes to criteria 1/2024 Line of Business section added. 3/2024 Intra-Cytoplasmic Sperm Injection (ICSI) criteria clarified 4/2024 Residency requirement removed 12/2024 Annual Review with no changes 5/2025 Increased storage time of gametes, embryos or other reproductive tissue 5 years for certain indications.
Added CPT 89258 to policy (no change to PA requirement) CPT 89344 and 89346 changed to covered with PA 10/2025 Re-formatted and added “Clinical Guidelines” section.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.