Point32Commercial Clinical Policy

Point32 Assisted Reproductive Technology Services – New Hampshire Products Form


Assisted Reproductive Technology Services

Notes: Coverage decisions for ART services will be based upon the member's past medical/infertility history, including but not limited to past infertility interventions.

Indications

(877679) Is the patient the recipient of the intended Assisted Reproductive Technology (ART) services? 
(877680) Is there a >5% chance of live birth as demonstrated by the treating provider? 
(877681) Does the patient naturally expect fertility or is experiencing menopause at a premature age? 
(877682) Has the patient been diagnosed with infertility after 6 months of attempting conception if over the age of 35, or after 1 year if 35 or younger? 
(877683) Has the patient completed four cycles of intrauterine inseminations (IUIs) with or without medication without conceiving? 

YesNoN/A
YesNoN/A
YesNoN/A

Sign up to see the rest of the questions

Unlock the remaining questions and the full coverage workflow.

Sign up for free
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... In Vitro Fertilization due to Inadvertent Ovarian Hyperstimulation.

Donor Egg
Transfer and Frozen Transfer
Single Embryo (SET) Embryo (FET) Intra-Cytoplastic Sperm Injections (ICSI)
Assisted Hatching (AH)

Gamete and Zygote Intrafallopian Transfer (GIFT & ZIFT)

Donor Sperm

Assisted Reproductive Technology Services – New Hampshire 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