Oscar Infertility Treatment (CG016) Form
This procedure is not covered
Infertility Diagnosis and Treatment
The Plan considers the diagnosis and treatment of infertility medically necessary when the cause of infertility is a result of anatomical, acquired disease, inherited disease or other conditions resulting in an inability to conceive or establish pregnancy. Basic services (e.g., diagnostic) to determine the cause of infertility may include semen analysis, serum hormone levels, hysterosalpingogram, and evaluation of ovulatory function. If basic infertility services do not result in a pregnancy, comprehensive services (e.g., treatment) may include surgical and non-surgical treatments (e.g., ovulation induction, intrauterine insemination).
Note: Services for infertility may include diagnosis, treatment, or fertility preservation, and coverage is subject to the terms, conditions, limitations of a member's policy and applicable state and federal law. Advanced reproductive technologies such as in vitro fertilization (IVF), gamete intrafallopian tube transfers (GIFT), zygote intrafallopian tube transfers (ZIFT), or donor services (oocyte, ovum, sperm) are also subject to the member's benefit plan for eligibility of coverage. Furthermore, infertility medications and delivery (e.g., pumps) may be subject to the member's pharmacy benefit plan.
Note: For sex reassignment surgery among transgender members who have iatrogenic infertility, coverage for fertility preservation (freezing egg, sperm) and/or other infertility services is subject to the member's policy and applicable state and federal law. Please review The Plan's Clinical Guideline: Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017) for sex reassignment procedures for gender dysphoria.
Definitions
"Infertility"
"Infertility" refers to the failure to establish a successful pregnancy after 12 months/cycles for women before 35 years of age, or after 6 months/cycles for women greater or equal to 35 years of age with unprotected heterosexual intercourse or therapeutic donor insemination. Infertility may be caused by disease, dysfunction, or malformation.
- Primary infertility refers to couples who have never established a pregnancy.
- Secondary infertility refers to couples who are experiencing infertility after having a history of establishing a pregnancy.
"Iatrogenic Infertility"
"Iatrogenic Infertility" refers to transient or permanent infertility caused by a necessary medical intervention such as chemotherapy, pelvic radiotherapy, gonadotoxic therapies, or the surgical removal of the reproductive organs for the treatment of disease or gender dysphoria.
"In Vitro Fertilization" (IVF)
"In Vitro Fertilization" (IVF) refers to a series of procedures from extracting egg and sperm from biological parents (or donors) to fertilize mature eggs with sperm in a lab. Then the fertilized egg/s (embryo) are transferred into the uterus of the biological mother, gestational carrier (no genetic connection to the embryo), or traditional surrogate (own egg is fertilized from the intended father to give birth. Or these embryos can be cryopreserved (frozen) for future use.
"Cryopreservation" for fertility preservation
"Cryopreservation" for fertility preservation refers to freezing eggs (oocytes), sperm, or embryos at a storage bank for future reproduction.
"Pregnancy"
"Pregnancy" refers to clinical pregnancy documented by ultrasonography, biochemical or histopathologic examination.
"Recurrent Pregnancy Loss"
"Recurrent Pregnancy Loss" refers to two or more failed pregnancies, or miscarriages, and is not considered infertility.
"Therapeutic Donor Insemination"
"Therapeutic Donor Insemination" refers to the process of inserting laboratory-processed sperm into the reproductive tract of a woman from a man who is not her intimate sexual partner for the purpose of initiating a pregnancy.
Clinical Indications
General Clinical Indications
The Plan considers infertility services medically necessary when the following criteria are met:
- The requested service is covered per the member's plan benefit policy; and
- The requested service is NOT associated with the reversal of voluntary sterilization for male (e.g., vasectomy) or female (e.g., tubal ligation) for primary purpose of preventing pregnancy;
- Infertility services are not being requested beyond 8 weeks of pregnancy; and
- Infertility is the result of disease, dysfunction, iatrogenic infertility (see Definitions above), or malformation.
- Infertility is not defined to include the inability to conceive due to lack of a sex partner;
- For ages <35, after trying to conceive after 12 months (including unprotected heterosexual intercourse and/or therapeutic donor insemination); and/or
- For ages ≥35, after trying to conceive after 6 months (including unprotected heterosexual intercourse and/or therapeutic donor insemination); and
- For comprehensive infertility services, clinical documentation indicates that basic fertility services did not result in a pregnancy; and
- For assisted reproductive technology, clinical documentation indicates that comprehensive fertility services did not result in a pregnancy and MCG A-0504 criteria is met; and
- For fertility preservation due to iatrogenic infertility, MCG A-0504 criteria is met. Fertility preservation related to sex reassignment surgery is subject to plan benefits.
For fertility preservation services due to iatrogenic infertility associated with sex reassignment surgery, the General Clinical Indications criteria and Gonadectomy and Hysterectomy section criteria must also be met in Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017).
California State and New York State Lines of Business
- Same-sex couples, non-binary, and transgender individuals are able to receive infertility services if medically appropriate.
- Oscar does not discriminate based on a member’s partnership status or sexual orientation.
- Notwithstanding, all members must meet the definition of infertility and the General Clinical Indications to meet medical necessity for infertility services.
Basic Infertility Services (Diagnosis)
Basic female infertility services may include:
- Initial Evaluation: History & Physical Exam
- Laboratory: Chlamydia Trachomatis screening, Rubella serology, viral status screening (HIV, Hepatitis B, Hepatitis C), TSH, Prolactin, FSH, Estradiol, Progesterone, Luteinizing Hormone, human chorionic gonadotropin, androgens (if there is evidence of hyperandrogenism), anti-mullerian hormone, Clomiphene citrate challenge test, Genetic karyotyping (Chromosome analysis)
- Imaging: Sonohysterography (Saline Infusion Sonography), Pelvic or Transvaginal Ultrasonography, Hysterosalpingography, Hysteroscopy, CT or MR imaging of sella turcica if prolactin is elevated
- Diagnostic Procedures: Laparoscopy and chromotubation
Basic male infertility services may include:
- Initial Evaluation: History & Physical Exam
- Laboratory: Chlamydia Trachomatis screening, viral status screening (HIV, Hepatitis B, Hepatitis C), TSH, FSH, LH, PRL, Total and free Testosterone (T), estrogens, Genetic karyotyping
- Post-Ejaculatory Urinalysis
- Imaging: CT or MR imaging of sella turcica if prolactin is elevated, Transrectal or Scrotal Ultrasonography, Vasography or Venography
- Tissue Analysis or Testis Biopsy
- Scrotal exploration
- Semen & Sperm Analysis
- Quantification of Leukocytes in Semen
- Sperm concentration and motility
- Seminal fructose
- Cultures of prostatic secretion, semen, urine
Comprehensive Infertility Services (Treatment)
Comprehensive female infertility services may include (please check the member’s plan benefit):
- Non-Surgical Treatments
- Endocrine management
- Gonadotropins, Gonadotropin releasing hormone (GnRH), Gonadotropin releasing hormone (GnRH) antagonists, Corticosteroids, Estrogens, Progestins, Aromatase inhibitors, Lutropin alfa in combination with human FSH
- Hepatitis B vaccination of partners of people with hepatitis B
- Rubella vaccination of women susceptible to rubella
- Oral clomiphene citrate, tamoxifen, or letrozole for ovulation induction (please check member’s pharmacy plan benefit)
- Metformin and/or letrozole for women with anovulatory disorders such as polycystic ovarian syndrome (please check member’s pharmacy plan benefit)
- Prolactin inhibitors for women with hyperprolactinemia
- Artificial/intrauterine insemination [IUI] (including sperm washing)
- Donor insemination for ONE of the following indications:
- Obstructive or non-obstructive azoospermia; or
- Severe deficits in semen quality in couples who do not wish to undergo intracytoplasmic sperm injection (ICSI); or
- Severe rhesus isoimmunization; or
- High risk of transmitting a genetic disorder or infectious disease (such as HIV) in the male partner to the offspring.
- Surgery and Imaging, when MCG criteria is met:
- Hysteroscopic adhesiolysis for women with amenorrhea and intrauterine adhesions
- Hysteroscopic or fluoroscopic tubal cannulation (salpingostomy, fimbrioplasty), selective salpingography plus tubal catheterization, or transcervical balloon tuboplasty for women with proximal tubal obstruction
- Laparoscopy for treatment of pelvic pathology
- Open or laparoscopic resection, vaporization, or fulguration of endometriosis implants plus adhesiolysis in women with endometriosis
- Ovarian wedge resection or ovarian drilling for women with polycystic ovarian syndrome who have not responded to clomiphene citrate and comparable estrogen modulators such as letrozole
- Removal of myomas, uterine septa, cysts, ovarian tumors, polyps, hydrosalpinx
- Surgical tubal reconstruction (unilateral or bilateral tubal microsurgery, laparoscopic tubal surgery, tuboplasty and tubal anastomosis), except in the case of prior tubal sterilization
Comprehensive male infertility services may include (please check the member’s plan benefit):
- Non-Surgical Treatments
- Non-parenteral (oral) endocrine management is subject to plan benefits:
- Androgens (e.g., testosterone) for men with documented androgen deficiency
- Anti-estrogens (e.g., tamoxifen) for men with elevated estrogen levels
- Selective estrogen receptor modulators (SERMs) and/or aromatase inhibitors (AIs) for men with documented testosterone deficiency
- Corticosteroids (e.g., dexamethasone, prednisone)
- Prolactin inhibitors (dopamine agonists e.g., bromocriptine, cabergoline) for men with hyperprolactinemia
- Thyroid hormone replacement for men with thyroid deficiency
- Antibiotics for men with an identified infection (note: intra-prostatic antibiotic injection is considered experimental and investigational)
- Injectable parenteral (subcutaneous/infusion pump) endocrine management is subject to plan benefits
- For men with primary or secondary hypogonadotropic hypogonadism that is not due to primary testicular failure:
- Human chorionic gonadotropins (hCG)
- Human menopausal gonadotropins (hMG) (menotropins)
- Gonadotropin releasing hormone (GnRH) (luteinizing hormone releasing hormone (LHRH)), by intermittent subcutaneous injections or by GnRH infusion pump
- Recombinant follitropin products (recombinant FSH) (e.g., follitropin alfa; follitropin beta)
- Human chorionic gonadotropins (hCG) for men with prepubertal cryptorchidism not due to anatomic obstruction.
- For men with primary or secondary hypogonadotropic hypogonadism that is not due to primary testicular failure:
- Electroejaculation for diabetic neuropathy, prior retroperitoneal surgery or spinal cord injury
- Non-parenteral (oral) endocrine management is subject to plan benefits:
- Surgery and Imaging, when MCG criteria are met:
- Varicocelectomy (spermatic vein ligation):
- For men with palpable varicocele(s), infertility, and abnormal semen parameters
- Not medically necessary for men with azoospermia
- Not medically necessary for non-palpable varicocele or those detected solely by imaging
- Spermatocelectomy and hydrocelectomy
- Surgical repair of vas deferens (e.g., vasovasostomy)
- Except when done for the reversal of a prior voluntary sterilization procedure such as vasectomy
- Surgical correction of epididymal blockage for men with obstructive azoospermia, including:
- Epididymectomy
- Epididymovasostomy
- Excision of epididymal tumors and cysts
- Epididymostomy
- Transurethral resection of ejaculatory ducts (TURED) for obstruction of ejaculatory ducts
- Orchiopexy
- For retrograde ejaculation the following is subject to plan benefits:
- Alpha sympathomimetic agents (for retrograde ejaculation)
- Alkalinization of the urine with or without ureteral catheterization
- Induced ejaculation (such as using sympathomimetics, vibratory stimulation, and/or electroejaculation)
- Surgical sperm retrieval (see below)
- Varicocelectomy (spermatic vein ligation):
Advanced Reproductive Technologies
Member meets General Criteria above and MCG A-0504 criteria is met.
Advanced Reproductive Technologies
Advanced reproductive technologies may include:
- In vitro fertilization (IVF)
- Gamete intrafallopian tube transfers (GIFT)
- Zygote intrafallopian tube transfers (ZIFT)
- Donor services (oocyte, ovum, sperm)
Fertility Preservation
Fertility preservation is subject to the member's plan benefit. The member meets medical necessity when the General Criteria above is met AND one of the below:
- MCG A-0504 criteria is met; or
- A member has a medical procedure/treatment that will lead to iatrogenic infertility.
Fertility preservation may include:
- Cryopreservation and storage of the following:
- Ejaculated or testicular sperm
- Embryo, with or without ovarian stimulation
- Mature oocytes
- Ovarian tissue for prepubertal patients or when there is not time for ovarian stimulation
- Gonadotropin releasing hormone (GnRH) agonists for patients with breast cancer and potentially other cancers for the purpose of protection from ovarian insufficiency
- Ovarian transposition (oophoropexy) for patients undergoing pelvic radiation
- Radiation (gonadal) shielding
- Cervicectomy/trachelectomy for patients with early stage (IA2 or small IB1) cervical adenocarcinoma
- Laparoscopic cystectomy for patients with ovarian endometriomas or early stage ovarian cancer
Experimental or Investigational / Not Medically Necessary
Services or procedures considered experimental, investigational, or unproven are not covered, including but not limited to:
- Acrosome reaction test
- Acupuncture
- Bariatric surgery
- Comet assay
- Computer-assisted sperm analysis (CASA)/computer-assisted sperm motion analysis
- Cryopreservation, storage, and thawing of immature oocytes
- Cryopreservation, storage, and thawing of testicular tissue
- Dehydroepiandrosterone (DHEA)
- Direct intra-peritoneal insemination, fallopian tube sperm transfusion, intra-follicular insemination, and the use of sperm precursors
- Double IUI (intrauterine insemination)
- Drainage of ovarian cyst, when billed for egg retrieval
- EmbryoGlue
- Endometrial receptivity testing, uterine receptivity testing
- Fine needle aspiration (\
- Endocrine management