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