Point32 Assisted Reproductive Technology Services – Massachusetts Products Form
This procedure is not covered
General information
Clinical Coverage Criteria
- ART/Infertility Services
ART/Infertility Eligibility Criteria
Evaluation Requirements for Intrauterine Insemination (IUI)
Evaluation Requirements for In Vitro Fertilization (IVF)
Intrauterine Insemination (IUI) Services
In Vitro Fertilization due to Inadvertent Ovarian Hyperstimulation.
Donor Egg
Single Embryo Transfer (SET) and Frozen Embryo Transfer (FET).
Intra-Cytoplastic Sperm Injections (ICSI) Assisted Hatching (AH) Gamete and Zygote Intrafallopian Transfer (GIFT & ZIFT).
Donor Sperm
Assisted Reproductive Technology Services – Massachusetts Products
- Microsurgical Epididymal Sperm Aspiration (MESA)
- Testicular Sperm Extraction (TESE)
- History of Prior Sterilization Reversal
Cryopreservation
Clinical Coverage Criteria for Cryopreservation of Sperm, Oocytes, or Embryos.
Limitations Administrative Process