Point32Commercial Clinical Policy

Point32 Assisted Reproductive Technology Services – Massachusetts Products Form


In vitro fertilization (IVF) and/or embryo transfer (ET)

Indications

(112925) Is the patient the recipient of the intended services? 
(112926) Does the patient's individual medical history demonstrate a > 5% chance of live birth? 
(112927) Is the patient expected to be fertile as a natural state or experiencing premature menopause? 

Contraindications

(112928) Is the patient seeking ART/infertility services solely for convenience, lifestyle, personal preference, or religious belief in absence of medical necessity? 
(112929) Has the infertility been a result of a prior voluntary sterilization or unsuccessful sterilization reversal procedure without meeting specific eligibility criteria? 
YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

09/01/2023

Last Reviewed

07/19/2023

Original Document

  Reference



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

References Approval