Point32Commercial Clinical Policy

Point32 In Vitro Fertilization (IVF) and Other Fertility Services CT Form


In Vitro Fertilization (IVF)

Notes: Coverage for medically necessary fertility services is limited. It is essential to confirm live birth probability, medical necessity, benefit cycle limitations, as well as compliance with standards and ethics.

Indications

(754404) Is the IVF procedure likely to result in viable offspring with greater than 5% probability? 
(754405) Is the IVF treatment for the patient medically necessary to diagnose and treat medical infertility? 
(754406) Does the patient have a referral from a Primary Care Physician (PCP) for specialist consultation (required for HMO members)? 
(754407) Will the fertility treatment or procedure be performed at a facility that conforms to standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility? 
(754408) Is this an authorized cycle of fertility treatment for the patient? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

08/01/2023

Last Reviewed

NA

Original Document

  Reference



Health Care

Harvard Pilgrim Medical Policy

In Vitro Fertilization (IVF) and Other Fertility Services CTSubject: In Vitro Fertilization (IVF) and Other Fertility Services CTContents

Background:

  • Authorization of Preimplantation Genetic Diagnosis (PGD)
  • POLICY AND COVERAGE CRITERIA FOR MEMBERS WITH UTERI/EGGS:
  • General eligibility criteria for Members with Uteri/Eggs
  • Assessment of ovary/Uterus FUNCTION:
  • Assessment of contributory testicles/Sperm:
  • Intrauterine Insemination (IUI)
    1. Initiation to IUI
    2. Continuing IUI
    3. IUI after in vitro fertilization
    4. Conversion to IVF from IUI with hyper-response
  • Fertility services
    1. In Vitro Fertilization (IVF) services
    2. In vitro fertilization service-specific criteria
    3. Cycle specifications and limitations
    4. Delivery protocols
  • SERVICE MAXIMUM
  • Gamete and Zygote Intrafallopian Transfer (GIFT & ZIFT)
  • Donor egg (donor oocyte)
  • Assisted Hatching (AH)
  • Reversal of prior sterilization
  • Oocyte stimulation, retrieval, and fertilization
  • Intracytoplasmic Sperm Injection (ICSI)
  • Cryopreservation of eggs and/or embryos
  • Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for a member in active authorized fertility treatment:
  • Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) anticipatory of medical treatment expected to impact fertility:
  • Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for members undergoing gender reassignment treatment:

Prior Authorization:

Authorization of Preimplantation Genetic Diagnosis (PGD)

POLICY AND COVERAGE CRITERIA FOR MEMBERS WITH UTERI/EGGS:

General eligibility criteria for Members with Uteri/Eggs

Assessment of ovary/uterus function:

Assessment of contributory testicles/sperm:

Intrauterine Insemination (IUI)
  1. Initiation to IUI
  2. Continuing IUI
  3. IUI after in vitro fertilization
  4. Conversion to IVF from IUI with hyper-response
Fertility services
  1. In Vitro Fertilization (IVF) services
    • In vitro fertilization service-specific criteria
    • Cycle specifications and limitations
    • Delivery protocols
    • Repeat cycle documentation
    • Service maximum
    • Gamete and Zygote Intrafallopian Transfer (GIFT & ZIFT)
  2. Donor egg (donor oocyte)
  3. Assisted Hatching (AH)
  4. Reversal of prior sterilization
  5. Oocyte stimulation, retrieval, and fertilization
  6. Intracytoplasmic Sperm Injection (ICSI)
Cryopreservation of eggs and/or embryos
  1. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for a member in active authorized fertility treatment:
  2. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) anticipatory to medical treatment expected to impact fertility:
  1. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for members undergoing gender reassignment treatment:

POLICY AND COVERAGE CRITERIA FOR MEMBERS WITH TESTICLES/SPERM:

HPHC Medical Policy6757675Page 1 of 15In Vitro Fertilization (IVF) and Other Fertility Services CTVF01AUG23PHPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Fertility services continued

  • Ta. Fertility confirmation requirement
  • Ib. Intracytoplasmic Sperm Injection (ICSI)
  • Id. Microsurgical Epididymal Sperm Aspiration (MESA)
  • Ie. Testicular Sperm Extraction (TESE) or Micro-TESE
  • If. Reversal of prior sterilization
  • II. Sperm collection and cryopreservation
  • Ila. Cryopreservation related to fertility or medical treatment
  • IIIb. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for members undergoing gender reassignment treatment

Exclusions:

Guidelines and benchmarks: