Aetna Infertility Coverage & Prior Auth Policy Update

Covered services and clinical criteria

Covered when ALL applicable plan provisions are met and when member meets the stated clinical criteria:

General eligibility: Member's plan must provide coverage for infertility services; coverage is subject to plan terms and state mandates

See plan documents

Definition of infertility: Failure to conceive after specified duration (12 months if female <35 years; 6 months if female >=35 years) OR defined cycles of timed insemination OR demonstration of reproductive tract disease making conception ineffective

Applies regardless of partner availability

Female diagnostic services covered: History and physical, specified laboratory testing (e.g., serum hormones including AMH, FSH/LH, prolactin, TSH; infectious disease screening), imaging and diagnostic procedures (endometrial biopsy, HSG, hysteroscopy, laparoscopy, transvaginal ultrasound) and monitoring of ovarian response

Some tests/procedures have appendix-specified limitations

Female non-surgical and surgical treatments: Medications (aromatase inhibitors, clomiphene, metformin, progestins, estrogens, selected corticosteroids), vaccinations, gynecologic surgeries (hysteroscopic adhesiolysis, tubal cannulation, laparoscopy, endometriosis surgery, ovarian drilling, tubal reconstruction, salpingectomy for hydrosalpinx when indicated)

Coverage may vary by plan; injectable medications often require precertification

Male diagnostic services covered: History and physical, semen analysis with repeat-testing rules, selected labs (hormones, genetic testing where indicated), imaging and testis/epididymal biopsy as clinically indicated

Some specialized seminal biochemical tests are considered investigational

Artificial insemination indications: IUI/ICI considered medically necessary for any of: mild male-factor infertility; unexplained infertility; minimal–mild endometriosis; refractory erectile dysfunction or vaginismus; HIV-positive male with sperm washing; couples undergoing menotropin stimulation; or clomiphene-stimulated AI in ovulatory WHO Group II disorders

Definition of mild male-factor: >=2 semen analyses at least 2 weeks apart with 1+ variables below 5th percentile

Advanced reproductive technologies (ART): IVF, FET, oocyte retrieval, sperm preparation, and related ART procedures are medically necessary when any ART criteria are met (e.g., failed trial of ovarian stimulation per age rules; tubal factor including bilateral disease; severe male-factor such that insemination unlikely to succeed; endometriosis stage III/IV; other conditions where insemination is unlikely to be effective)

Coverage limited to plans with an ART benefit; ICSI medically necessary for specified sperm/ fertilization indications

Medication therapy criteria: Gonadotropins (follitropins, menotropins, hCG) are medically necessary when indicated per drug-specific initial approval criteria (e.g., prior clomiphene cycles, risk factors for poor response, contraindication to clomiphene, or age >=37 where specified); continuation requires meeting initial authorization criteria

Many plans exclude injectable infertility medications; precertification may be required

Cryopreservation indications: Cryopreservation of gametes or embryos is medically necessary when undertaken for iatrogenic infertility risk (e.g., chemotherapy, pelvic radiotherapy, gonadectomy); routine/elective cryopreservation to circumvent aging is not covered

Some plans exclude storage/cryopreservation fees—check benefits

Medical necessity: Artificial insemination, ART, continuation therapy, cryopreservation

Covered when ALL/ANY as specified below

Artificial insemination medical necessity: Artificial insemination (ICI or IUI) is medically necessary for any of: mild male-factor infertility; unexplained infertility; minimal to mild endometriosis; medically refractory erectile dysfunction or vaginismus preventing intercourse; HIV-positive male with sperm washing; couples undergoing menotropin ovarian stimulation; or clomiphene-stimulated AI for WHO Group II ovulation disorders who ovulate with clomiphene but have not become pregnant.

Mild male-factor defined by >=2 semen analyses at least 2 weeks apart with 1+ variables below 5th percentile

ART medical necessity: ART procedures (including IVF with embryo transfer, FET, oocyte retrieval, sperm preparation, ICSI when indicated, GIFT/ZIFT for female factor) are medically necessary when any of: failed trial of ovarian stimulation per age-based rules (3 cycles if <=37; none required if >=38); conditions where insemination unlikely to be effective (e.g., azoospermia, severe semen deficits, bilateral tubal disease, endometriosis stage 3/4); failure to conceive after pelvic reconstruction per timeframes; ectopic pregnancy during infertility treatment; unilateral hydrosalpinx meeting timing criteria; women post-hysterectomy or with contraindication to pregnancy where gestational carrier indicated.

ICSI indicated for azoospermia/oligospermia, severe semen deficits, fertilizing frozen oocytes, iatrogenic infertility, or prior failed/poor fertilization; ICSI not necessary if sperm normalized after varicocelectomy

Ovarian stimulation coverage criteria

Covered when ALL of the following are met

Ovarian responsiveness criteria: Member demonstrates biologic capacity to respond to ovarian stimulation as evidenced by an unmedicated day-3 FSH obtained within the prior 6 months for women older than 35 years or within the prior 12 months for women age 35 or youngerDay-3 FSH timing per age

In women >40 any single FSH >19 mIU/mL indicates ovarian insufficiency; in women <40 responsiveness shown by any unmedicated day-3 FSH <19 mIU/mL

Evidence-based coverage statements

Coverage stance based on cited evidence and guideline statements:

Luteal phase support: Progesterone is the preferred agent for luteal phase support in ART; hCG is associated with increased OHSS risk and should be avoided; addition of GnRH agonist to progesterone showed benefit in some trials

Based on Cochrane review of 69 studies (progesterone benefit; hCG increased OHSS; some benefit with progesterone + GnRH agonist)

In‑vitro maturation (IVM): IVM and cryopreservation of immature oocytes are considered experimental and should be limited to specialized centers and research settings until RCT evidence supports routine use

No suitable RCTs for IVM vs conventional IVF in PCOS

Preimplantation genetic screening/diagnosis (PGS/PGD-A): PGS#2 and PGD-A have uncertain clinical utility; evidence is mixed and procedure should be considered experimental outside study conditions

Lack of properly conducted intent-to-treat trials; professional societies caution use

Evidence summaries (informational)

Evidence and clinical conclusions relevant to coverage decisions:

Eeva time‑lapse embryo assessment: Time‑lapse Eeva scoring improves embryologist specificity for selecting embryos likely to reach usable blastocyst stage in cohort studies, but current evidence is insufficient to support routine clinical use for improving embryo selection

Prospective cohort and multicenter studies showed improved specificity and implantation associations; overall evidence deemed inadequate for routine use

DuoStim evidence summary: DuoStim (double stimulation within one ovarian cycle) increases oocyte and euploid blastocyst yield in poor‑prognosis cohorts, with comparable competence of luteal‑phase oocytes, but lacks RCTs and long‑term safety/cost‑effectiveness data

Observational and paired studies report higher oocyte/euploid yield; authors recommend limiting to poor prognosis/time‑critical patients pending further trials

POLG CAG‑repeat testing: Meta-analysis found no association between POLG CAG‑repeat polymorphisms and male infertility; testing for this variant is not supported by current evidence

Pooled case‑control studies did not demonstrate association

Coverage and use criteria

Coverage stance based on current evidence in included chunks

DuoStim — conditional coverage: DuoStim may be considered only for poor‑prognosis patients and/or when time is critical, pending further randomized trials and safety data

Authors recommend restricting use until RCTs and safety/cost data are available

ERA — selective/research use: ERA demonstrated per‑protocol benefits in one RCT but ITT results were limited; routine use in unselected first autologous euploid FET cycles is not supported — consider ERA only in research protocols or selected populations (e.g., recurrent implantation failure) with documented counseling

Mixed evidence from RCT and cohort studies; further trials required

Vaginal microbiota and telomere associations: Associations exist between high‑Lactobacillus vaginal microbiota and infertility outcomes and between telomere metrics and infertility factors, but causal inference and clinical application are not established

Further high‑quality studies required before routine clinical application

Coverage summaries for interventions discussed

Summary coverage stance based on cited evidence

PICSI (hyaluronan‑selected ICSI) is not recommended for routine use to improve term live‑birth rates based on a large randomized trial showing no significant difference versus standard ICSI

Large RCT (HABSelect) showed no term live‑birth benefit

Intralipid and immunotherapies: Immunotherapies including intralipid infusion are investigational for improving live‑birth outcomes and should be limited to research contexts

Systematic reviews/meta‑analyses show controversial results and insufficient evidence for routine use

Platelet‑rich plasma (PRP): PRP shows inconsistent evidence for thin endometrium and recurrent implantation failure; further large RCTs are required before routine adoption

Systematic reviews indicate increased implantation/clinical pregnancy in some small studies but require confirmation

Intrauterine hCG may improve outcomes for cleavage‑stage embryo transfers at doses >=500 IU, but evidence is heterogeneous and stage/dose dependent

Evidence summaries and clinical considerations

Summaries of evidence and clinical considerations for interventions

Stem cell therapy for ovarian disorders: Systematic reviews suggest potential for ovarian tissue rejuvenation in POI models but evidence is preliminary and largely preclinical or early‑phase clinical; not routine care

UpToDate does not list stem cell therapy as a treatment option

Uterine transplantation (UTx) for AUFI: UTx can restore fertility in AUFI with reported live births, but is experimental with significant risks (graft failure, post‑op complications, hysterectomy in some recipients, high preterm birth rates); multidisciplinary evaluation and informed consent are essential

Evidence is interim; centers should follow strict protocols

Vaginal sildenafil for thin endometrium: Small RCTs and pilot studies show mixed results; insufficient evidence to support routine use

Findings inconsistent; not standard therapy per UpToDate

Medically necessary laboratory and medication management

Laboratory services and medication vial management per cycle considered medically necessary when consistent with infertility treatment monitoring and FDA‑recommended dosing.

Laboratory monitoring per cycle: Transvaginal ultrasound and serial serum measurements (estradiol, FSH, LH, progesterone, quantitative hCG) at frequencies specified in the laboratory services per‑cycle table are medically necessary for cycle monitoringsee appendix table

More than 2 progesterone measurements may be necessary for irregular cycles

Gonadotropin vial limits and dosing: Gonadotropin and menotropin vial/cartridge limits per 28 days and FDA‑recommended dosing (product‑specific maxima and starting doses) must be followed; standard limits and maximum daily doses are provided in the appendixproduct‑specific maxima (e.g., follitropin alfa max daily 300–450 IU depending on indication; follitropin beta max daily up to 500 IU for ART)

Dosing individualized based on prior response; refill rules per cycle sheets

Treatment selection and sequencing

Treatment sequencing and choice considerations

Initial approach for most couples: Begin with clomiphene citrate (CC)/IUI which yields pregnancy in approximately 25% of couples and has low multiple‑birth risk and low cost; accelerated IVF approaches may shorten time to pregnancy for appropriate patientsage‑related considerations apply

Consider patient age and preferences when sequencing treatments

When to consider gonadotropins or IVF: After failure of CC (e.g., after 6 ovulatory CC cycles), clinicians may switch to gonadotropins with or without IUI or proceed to IVF; gonadotropins increase live‑birth but at higher cost and resource useafter 6 ovulatory CC cycles

Gonadotrophins showed higher live‑birth (52% vs 41%) with higher ICER

Avoid COH‑IUI in patients with poor Day‑3 labs: Women with Day‑3 FSH 10–15 mIU/mL and estradiol >=40 pg/mL are unlikely to achieve live‑birth with COH‑IUI; consider proceeding directly to IVF

Definition-based criteria

Covered definitions when used to evaluate infertility conditions and ART outcomes:

Embryo quality: An embryo of reasonable quality (grade B or equivalent) is defined as having less than 50% fragmentation<50% fragmentation

Used to qualify embryos for transfer or cryopreservation

Fertilization rate: IVF cycles with less than 50% fertilization are considered to have poor fertilization<50% fertilization

May guide indications for techniques like ICSI

Ovarian reserve response: Normal ovarian reserve response after gonadotropin stimulation: 3 or more follicles develop and peak estrogen >500 mIU/ml; diminished reserve indicated by peak estrogen <500 mIU/ml or fewer than 3 mature follicles>=3 follicles; peak estrogen >=500 mIU/ml

Most Aetna plans exclude coverage for infertility services following prior sterilization procedures (including tubal sterilization and vasectomy) and for persons who have undergone hysterectomy; such services are considered elective and not treatment of disease. Providers should check the member’s benefit plan description for plan-specific exclusions and limitations. (See examples and plan-check note in policy.)

Surgical reversal of sterilization (e.g., tubal anastomosis or vasovasostomy) and related services are generally not covered under plans that specifically exclude services after voluntary sterilization; verify member benefits before authorization.

IVF cycles performed solely for the purpose of embryo banking (when embryos are created but none are used in the contemporaneous cycle) and routine gamete cryopreservation to delay reproductive aging in healthy persons are considered elective and are not covered. Cryopreservation and long‑term storage charges for donor or elective gamete/embryo services may be excluded by some plans; verify plan provisions.

Cryopreservation of mature gametes or embryos is considered medically necessary only for persons facing iatrogenic infertility (for example, due to chemotherapy, pelvic radiotherapy, or planned gonad removal). Cryopreservation of immature gametes (and IVM of immature oocytes) is considered experimental/investigational and is not routinely covered.

The policy lists specific CPT/HCPCS and related codes that are not covered for the indications described in this Clinical Policy Bulletin (examples include codes for certain genetic evaluations, Endometrial Receptivity Analysis/ERA, cryopreservation of immature oocytes, and selected HCPCS listed as not covered). Providers should consult the CPB code lists when determining coverage for services.

Examples of HCPCS/CPT entries cited as not covered for CPB indications include hyaluronan sperm binding testing (0087T), platelet-rich plasma injections (0232T), cryopreservation of immature oocytes (0357T), and assorted HCPCS items enumerated in the policy appendix; certain ICD-10 codes (e.g., N92.4, N95.0–N95.9) are also identified as not covered for listed indications.

For women under age 40, ovarian responsiveness for use of their own oocytes is demonstrated by an unmedicated day‑3 serum FSH of < 19 mIU/mL on the most recent test. For women age 40 and older, any single unmedicated day‑3 FSH > 19 mIU/mL indicates ovarian insufficiency and precludes use of own oocytes unless a subsequent test documents FSH < 19 mIU/mL as specified by plan rules.

When premature ovarian failure (primary ovarian insufficiency) is present, oocyte donation is an accepted effective option and ART using donor oocytes is considered medically necessary up to age 45 per the policy; check plan details for any age‑based limits.

The policy identifies specific ICD‑10 diagnosis codes that are not covered for the indications listed in this CPB; examples called out include codes for menopausal and perimenopausal disorders and selected menstrual disorder codes (for example, N92.4 and N95.0–N95.9). Providers should use the CPB code lists and verify applicable plan coverage before submitting claims.

Additional ICD‑10 entries referenced in the appendix (e.g., Z31.0 for reversal of previous sterilization, Z78.0 asymptomatic menopausal state, and Z90.* acquired absence codes) are shown for guidance on applicable and excluded diagnoses; applicability depends on the plan.

The policy characterizes several procedures and techniques as experimental or investigational and not standard care outside research settings. These include updated preimplantation genetic screening (PGS#2/PGT‑A) where intent‑to‑treat RCT evidence is lacking, in‑vitro maturation (IVM) and cryopreservation of immature oocytes, and other emerging genetic or laboratory methods without validated clinical utility.

Procedures considered experimental should generally be limited to specialized centers or study protocols and typically require case review or prior authorization when proposed outside research.

Eeva (Early Embryo Viability Assessment) time‑lapse embryo scoring has shown improved specificity for predicting embryos that reach blastocyst stage in some cohort studies, but the CPB concludes that current evidence is insufficient to support routine clinical use of the Eeva test for embryo selection.

Endometrial Receptivity Analysis (ERA) is an add‑on test that uses endometrial biopsy RNA profiles to classify the endometrium as receptive or non‑receptive and to guide personalized embryo transfer timing. Evidence is mixed: one RCT reported per‑protocol benefits but ITT analyses and cohort studies have not consistently shown improved live‑birth rates.

Given current uncertainty, routine, widespread use of ERA as an add‑on is discouraged; ERA should be offered primarily under research protocols or selectively for patients with specific indications (for example, documented prior failed embryo transfer) with counseling and prior authorization as appropriate.

Immunotherapies (including intralipid infusion) and stem cell–based therapies for infertility are considered experimental or investigational. Systematic reviews and meta‑analyses report controversial and inconsistent results; current evidence does not support routine clinical use outside research settings.

Stem cell approaches for ovarian rejuvenation and related interventions remain preliminary (mostly preclinical or early‑phase clinical data); UpToDate and guideline sources do not list stem cell therapy as an established treatment for female infertility.

Uterine transplantation (UTx) for absolute uterine factor infertility is described as an experimental, complex surgical intervention. Although UTx can restore uterine function in some recipients, evidence remains preliminary and optimal donor/recipient selection criteria are not yet established.

UTx carries substantial perioperative morbidity and obstetric risks; prior authorization, rigorous multidisciplinary candidate evaluation, and center‑level expertise are recommended when considering this therapy.

Some plans expressly exclude infertility services for ovarian failure or for services related to voluntary sterilization; providers must verify member benefit plan descriptions to confirm coverage eligibility prior to initiating services.

The CPB is a partial description of benefits and does not itself determine coverage—plan documents govern specific exclusions and limits.

Intracytoplasmic sperm injection (ICSI) is medically necessary for clear indications such as azoospermia, severe oligoasthenoteratozoospermia, fertilization failure with prior IVF cycles, or to fertilize cryopreserved oocytes. However, ICSI is considered not medically necessary when previous severe male‑factor infertility has been corrected (for example, successful varicocelectomy resulting in normalization of sperm quality/quantity).

When sperm parameters normalize after corrective surgery (documented on repeat semen analyses performed at least two weeks apart), routine use of ICSI is not supported.

The references section of the Clinical Policy Bulletin provides bibliographic citations used to support policy statements. This portion is references‑only and does not itself state coverage exclusions or policy criteria.

This Clinical Policy Bulletin provides a summary of Aetna’s coverage approach for infertility services but is not a contract and does not replace member benefit plan documents. Coverage decisions depend on the member’s specific contract terms, state mandates, and plan exclusions; providers should verify benefits prior to treatment.

Diagnostic procedures cited as examples include saline infusion sonohysterography/salino‑hysterosalpingography (e.g., Femvue) for tubal screening and selected seminal biochemical tests (such as seminal alpha‑glucosidase) used in specialized evaluations. The policy lists these procedures among many diagnostic options but also notes some are considered investigational for routine screening.

Semen biochemical assays and specialized seminal function tests are generally considered experimental/investigational when used for routine infertility evaluation; refer to the CPB lists for specific items and coverage stance.

The CPB enumerates a long list of procedures and laboratory tests that are considered experimental, investigational, or not medically necessary for routine infertility management. Examples include many sperm function tests (acrosome reaction, hemizona, hyaluronan binding, ROS, DNA fragmentation assays), endometrial receptivity testing (ERA/EFT), PGT‑A/PGS for routine IVF optimization, intralipid infusion, intrauterine platelet‑rich plasma infusion, DuoStim outside select poor‑responder contexts, and stem cell therapies.

Providers should consult the detailed policy lists when planning diagnostic or adjunctive procedures; many of these services are not supported by high‑quality evidence for routine use and may be denied if billed without documented experimental/research context.

The policy appendix provides explicit lists of HCPCS codes and CPT codes that are not covered for CPB‑specified indications (examples include certain HCPCS listed under 'not covered' such as topical hyperbaric oxygen chamber A4575 and specific immune globulin J‑codes).

Providers should use the CPB’s coding tables to confirm whether a given CPT/HCPCS code is listed as not covered for the indicated infertility purpose prior to claim submission or authorization requests.

Routine screening with anti‑mullerian hormone (AMH) to detect diminished ovarian reserve in low‑risk populations is not recommended. While AMH correlates with ovarian function and is useful in high‑risk women or for individualized controlled ovarian stimulation, evidence is insufficient to support AMH as a population screening tool.

Use AMH selectively to inform treatment planning (for example, to individualize stimulation dosing) rather than as routine screening in asymptomatic, low‑risk persons.

The routine use of adjuvant growth hormone (GH) in IVF protocols is not established. Meta‑analysis found no overall benefit in general IVF populations, although limited data suggest potential benefit in certain poor‑responder subgroups; further research is needed before routine adoption.

Testing for Th1/Th2 ratios and intracellular cytokine assays is not supported as medically necessary for routine infertility evaluation due to lack of evidence demonstrating clinical utility. Major clinical reviews and UpToDate do not endorse these assays for management decisions.

POLG CAG‑repeat testing is not supported as a diagnostic marker for male infertility. A pooled meta‑analysis found no association between POLG CAG‑repeat polymorphisms and male infertility and therefore routine testing for this variant is not recommended.

ERA is not supported for routine use in unselected patients undergoing a first autologous single euploid programmed frozen embryo transfer (FET). Cohort and controlled studies, including a prospective cohort and retrospective analyses, did not demonstrate consistent improvement in live‑birth rates in unselected first‑time euploid FET cycles.

ERA may be considered selectively (for example, in patients with documented prior implantation failures) and preferably under research protocols until stronger evidence supports broader clinical use.

Physiologic sperm selection (PICSI) did not significantly improve full‑term live‑birth rates compared with standard ICSI in a large randomized trial and therefore is not recommended for routine use.

Empiric intralipid infusion and other immunotherapies lack consistent high‑quality evidence of benefit and should be considered investigational outside research settings.

Vaginal sildenafil for improving endometrial thickness or fertility outcomes is not an established therapy. UpToDate and guideline sources do not list sildenafil as a standard treatment option for female infertility, and available trials provide mixed or insufficient evidence.

Controlled ovarian hyperstimulation with IUI (COH‑IUI) is unlikely to be beneficial for women whose Day‑3 testing shows FSH in the 10–15 mIU/mL range together with estradiol ≥ 40 pg/mL. In the referenced analyses this hormonal profile predicted no live births with COH‑IUI (100% specificity/PPV); consider proceeding directly to IVF for such patients.

When Day‑3 FSH is 10–15 mIU/mL and E2 ≥ 40 pg/mL, counseling and treatment planning should reflect the low likelihood of COH‑IUI success.

When a man previously met criteria for severe male‑factor infertility but subsequently normalizes sperm parameters after successful varicocelectomy (documented on repeat semen analyses), ICSI is considered not medically necessary; documentation of post‑operative normalization should be provided.

Providers should document semen parameters on at least two occasions as specified and review prior surgical corrections before proceeding with ICSI, since coverage may be denied when semen quality has normalized after corrective treatment.

This section of the Clinical Policy Bulletin contains the bibliographic references that support the policy text. Reference listings do not themselves confer coverage; they are provided for clinical and evidentiary context.

Applicable Codes and Key Clinical Thresholds

Applicable CPT / HCPCS codes listedmixed

0167U	Gonadotropin, chorionic (hCG), immunoassay with direct optical observation, blood.
0353U	Infectious agent detection by nucleic acid (DNA), Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique, urine, vaginal, pharyngeal, or rectal, each pathogen reported as detected or not detected.
49203	Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less.
49204	Largest tumor 5.1 - 10.0 cm diameter.
49205	Largest tumor greater than 10.0 cm diameter.
49320	Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).
49321	Laparoscopy, surgical; with biopsy (single or multiple).
49322	With aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple).
52402	Cystourethroscopy with transurethral resection or incision of ejaculatory ducts.
54500	Biopsy of testis, needle (separate procedure).

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Covered CPT Codes (procedures)CPTCovered

58660	Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
58661	With removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58662	With fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
58672	With fimbrioplasty
58673	With salpingostomy (salpingoneostomy)
58700	Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
58970	Follicle puncture for oocyte retrieval, any method
58974	Embryo transfer, intrauterine
58976	Gamete, zygote, or embryo intrafallopian transfer, any method

Imaging and radiology CPT CodesCPTCovered

70480	Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material
70540	Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)
74740	Hysterosalpingography, radiological supervision and interpretation
76830	Ultrasound, transvaginal
76831	Saline infusion sonohysterography (SIS), including color flow Doppler, when performed
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

Laboratory and andrology CPT CodesCPTCovered

82166	Anti-mullerian hormone (AMH)
82670	Estradiol
84144	Progesterone
84146	Prolactin
84443	Thyroid stimulating hormone (TSH)
89300	Semen analysis; presence and/or motility of sperm including Huhner test (post coital)
89310	Motility and count (not including Huhner test)
89337	Cryopreservation, mature oocyte(s)

Specialty and case-rate CPT/HCPCS/T codesmixedCovered

0087T	Sperm evaluation, Hyaluronan sperm binding test
0232T	Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
0357T	Cryopreservation; immature oocyte(s)
0664T	Donor hysterectomy (including cold preservation); open, from cadaver donor
S4011	In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
S4016	Frozen in vitro fertilization cycle, case rate
S4035	Stimulated intrauterine insemination (IUI), case rate
S4040	Monitoring and storage of cryopreserved embryos, per 30 days

HCPCS / J-codes / medication administration codesHCPCSCovered

A9574	Air polymer-type a intrauterine foam, 0.1 ml
G0010	Administration of hepatitis B vaccine
J2675	Injection, progesterone, per 50 mg
J9218	Leuprolide acetate, per 1 mg
S0126	Injection, follitropin alfa, 75 IU
S0187	Tamoxifen citrate, oral, 10 mg

Other HCPCS/related codesHCPCS

G0310	Immunization counseling by a physician or other qualified health care professional when the vaccine(s) is not administered on the same date of service, 5 to 15 mins time
S4027	Storage of previously frozen embryos
S4042	Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management of the patient), per cycle
S8930	Electrical stimulation of auricular acupuncture points; each 15 minutes

ICD-10 covered diagnoses (examples listed)ICD-10Covered

B20	Human immunodeficiency virus [HIV] disease [HIV positive male undergoing sperm washing]
E28.2	Polycystic ovarian syndrome
E28.39	Other primary ovarian failure [poor ovarian reserve, spontaneous primary ovarian insufficiency]
N97.0 - N97.9	Female infertility
Z31.41	Encounter for fertility testing
Z52.810 - Z52.819	Egg (Oocyte) donor

HCPCS codes listed as not covered for CPB indications (examples)HCPCSNot Covered

S8930	Electrical stimulation of auricular acupuncture points; each 15 minutes
A4575	Topical hyperbaric oxygen chamber, disposable
J1561	Injection, immune globulin, (Gamunex-C/Gammaked), nonlyophilized (e.g. liquid), 500 mg

Applicable ICD-10 codesICD-10

R93.811 - R93.9	Abnormal findings on diagnostic imaging of other specified body structures [follow-up on hysterosalpingography abnormalities]
T50.905+	Adverse effect of unspecified drugs, medicaments and biological substances
T66.xxx+	Radiation sickness, unspecified, initial encounter
Z11.3	Encounter for screening for infections with a predominantly sexual mode of transmission [Chlamydia trachomatis screening]
Z14.01 - Z14.02	Hemophilia A carrier
Z14.1	Cystic fibrosis carrier
Z14.8	Genetic carrier of other disease [high-risk of transmitting a genetic disorder from the female partner to the offspring]
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases [partners of persons infected with hepatitis B]
Z21	Asymptomatic human immunodeficiency virus [HIV] infection status
Z23	Encounter for immunization [rubella] [women susceptible to rubella]

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Additional ICD-10 codesICD-10

Z31.0	Encounter for reversal of previous sterilization
Z78.0	Asymptomatic menopausal state
Z79.890	Hormone replacement therapy
Z90.79	Acquired absence of other genital organ(s)
Z98.51 - Z98.52	Sterilization status

Laboratory and medication items (no explicit billing codes provided in this excerpt)mixed

No codes listed

No codes listedmixed

No codes listed

Day 3 FSH threshold

Day-3 FSH threshold (women <40)Unmedicated Day‑3 FSH < 19 mIU/mL in the most recent test

Women 40 and older — useown‑egg ruleUnmedicated Day‑3 FSH must be < 19 mIU/mL in all prior tests to use own eggs

Timing windows for Day‑3 FSHObtain unmedicated Day‑3 FSH within prior 6 months if >35 years or within prior 12 months if ≤35 years

Ovarian stimulation trial requirement

Ovarian stimulation trial requirement (≤37 years)Requirement: completion of 3 cycles of ovarian stimulation (with or without IUI) before ART is considered

Ovarian stimulation trial requirement (≥38 years)No trial of ovarian stimulation required prior to ART

ApplicabilityRequirement applies when plan limits ART to persons who are infertile and meet age-based criteria; check plan documents

Artificial insemination cycle limit (plan-dependent)

Typical lifetime limitArtificial insemination cycles typically limited to 6 cycles per lifetime under plans that cover AI

Plan variationSome Aetna plans may exclude AI entirely or apply different limits — verify benefit plan descriptions

ScopeLimit applies to covered AI services (IUI/ICI) when plan provides AI benefit

Embryo culture duration

Extended embryo culture durationExtended culture of oocyte(s)/embryo(s) for 4–7 days (CPT 89272)

CPT mappingCPT code 89272 corresponds to extended culture (4–7 days)

Use caseApplies to blastocyst-stage culture when clinically indicated

Day 3 FSH thresholds and timing windows for ovarian responsiveness

Demonstrating ovarian responsivenessUnmedicated Day‑3 FSH obtained within prior 6 months if >35 years or within prior 12 months if ≤35 years

Responsiveness threshold (women <40)Any unmedicated Day‑3 FSH < 19 mIU/mL indicates capacity to respond to stimulation in women <40

Insufficiency threshold (women >40)Any single Day‑3 FSH > 19 mIU/mL in women >40 indicates ovarian insufficiency

IL-17 plasma level associated with negative fertility impact

IL‑17 plasma level threshold> 3.42 pg/ml associated with negative impact on fertility

Study contextFinding reported from case‑control study comparing infertile versus fertile women with cytokine panels measured on day 21

InterpretationElevated IL‑17 (>3.42 pg/ml) correlated with infertility but clinical utility not established for routine testing

Functional ovarian cyst size used in included studies

Functional ovarian cyst size used in studies> 20 mm (simple, functional cyst) used as definition in included trials

Study implicationCysts >20 mm were the threshold used to evaluate cyst aspiration versus conservative management prior to COH

Evidence conclusionNo conclusive benefit of cyst aspiration vs conservative management on clinical pregnancy in included trials

IL-17 plasma level

IL‑17 plasma level (duplicate)> 3.42 pg/ml associated with negative impact on fertility

Source studyCase‑control study measuring multiple cytokines on day 21; IL‑17 elevated in infertile group

Clinical noteReported association does not establish routine diagnostic use; further research needed

Basal Day-3 testing thresholds predicting COH-IUI futility

Basal Day‑3 thresholds predicting COH‑IUI futilityFSH 10–15 mIU/ml together with E2 ≥ 40 pg/ml predicted no live‑birth with COH‑IUI (100% specificity/PPV in analysis)

Clinical implicationPatients meeting these basal hormone criteria are unlikely to benefit from COH‑IUI; consider proceeding to IVF

Evidence sourceSecondary analysis of FASTT and FORT‑T RCTs (n=603; 2,717 cycles) reporting group 2B outcomes

Day-3 hormone thresholds predicting COH-IUI futility (FSH 10-15 mIU/ml AND E2 >= 40 pg/ml)

Specific Day‑3 hormone futility thresholdFSH 10–15 mIU/ml AND estradiol (E2) ≥ 40 pg/ml predict no live‑birth with COH‑IUI

Evidence metricIn referenced analysis, specificity and PPV for no live‑birth with COH‑IUI were 100% for this profile

Recommended actionAvoid COH‑IUI in patients with this hormonal profile; consider IVF

Embryo/fertilization quality thresholds

Embryo fragmentation thresholdAn embryo with < 50% fragmentation is considered reasonable quality (grade B equivalent)

Fertilization rate thresholdIVF cycles with fertilization rate < 50% are considered poor

Clinical useThese thresholds inform decisions about cycle outcome classification and potential next‑step interventions

Follicle count after stimulation

Follicle count after gonadotropin stimulation>= 3 follicles indicates normal ovarian reserve/adequate response to stimulation

Associated estrogen thresholdNormal response also defined by peak estrogen > 500 mIU/ml after hyperstimulation

Diminished responsePeak estrogen < 500 mIU/ml or fewer than 3 mature follicles indicates diminished ovarian reserve

Peak estrogen level threshold for reserve

Peak estrogen level threshold>= 500 mIU/ml after gonadotropin stimulation indicates normal ovarian reserve

Below thresholdPeak estrogen < 500 mIU/ml indicates diminished ovarian reserve

ContextUsed together with follicle count (>=3) to define normal ovarian reserve response

IVF fertilization rate

IVF fertilization rate — poor cutoffFertilization rate < 50% in an IVF cycle is considered poor

ImplicationPoor fertilization rates may prompt consideration of ICSI or review of sperm factors and laboratory technique

Definition sourceAppendix definitions in policy document

Severe total motile sperm (unwashed) threshold

Severe total motile sperm (unwashed)< 10 million total motile sperm (TMS) per ejaculate (unwashed) constitutes severe quantity deficit

Measurement requirementDeficit should be documented on two separate occasions at least 2 weeks apart

Clinical consequenceSevere semen quantity may indicate need for ART/ICSI or surgical sperm retrieval as indicated

Severe total motile sperm (washed) threshold

Severe total motile sperm (washed)< 3 million total motile sperm (TMS) on washed specimen constitutes severe deficit

DocumentationRequire two separate abnormal results at least 2 weeks apart to define severe deficit

Clinical implicationSevere washed TMS supports consideration of ART such as ICSI or use of donor sperm depending on context

Kruger strict morphology threshold (<4% normal forms)

Kruger strict morphology threshold< 4% normal forms by Kruger strict criteria indicates severe morphology deficit

AssessmentKruger strict morphology used to define severe semen quality deficits in policy

Clinical relevanceSevere morphology may prompt ICSI or further male fertility evaluation

Precertification, Prior Authorization, and Documentation Requirements

Prior Authorization

Precertification Required

Precertification is required for listed infertility injectable medications (eg, Cetrotide, ganirelix acetate, Follistim AQ, Gonal‑F, Menopur, Novarel, Pregnyl, Ovidrel, and chorionic gonadotropin). Contact Aetna Precertification at (866) 782-2779 or fax (860) 754-2515. Statement of Medical Necessity (SMN) forms are available on the Aetna Specialty Pharmacy Precertification forms page and may be required for review. Failure to obtain required precertification may result in claim denial.

Precertification contact: (866) 782-2779; fax: (860) 754-2515
SMN forms: Aetna Specialty Pharmacy Precertification forms

Prior Authorization

Prior Authorization May Be Required for IVF/Case‑Rate Services

Prior authorization (medical authorization) may be required for IVF and related case‑rate services and certain ART cycle codes; selection of case‑rate or cycle codes and authorization should be confirmed during benefit verification. For some plans ART/IVF is limited to persons meeting specific infertility or ART benefit criteria — check member’s benefit plan for ART coverage limits.

IVF/case‑rate HCPCS examples: S4011, S4013–S4018, S4020–S4023, S4025–S4030, S4035, S4037, S4027, S4040, S4042
Verify ART benefit and obtain medical authorization prior to ordering/administration

Denial Risk

Prior Authorization for Experimental or Uncertain Procedures

Prior authorization is recommended for procedures considered investigational, experimental, or of uncertain clinical benefit (eg, in‑vitro maturation [IVM], many add‑on immunotherapies, certain forms of expanded PGD/PGS, some novel laboratory or surgical procedures). Experimental status may lead to denial; these services should generally be performed only in research settings or specialized centers and require prior review.

IVM and cryopreservation of immature oocytes: considered experimental; restrict to specialized centers
Add‑on procedures lacking high‑quality evidence (eg, many immunotherapies, unproven PGS/PGD approaches): prior review recommended

Prior Authorization

Prior Authorization Suggested for DuoStim and ERA

DuoStim (double stimulation) and Endometrial Receptivity Analysis (ERA) are emerging/limited‑evidence strategies. Prior authorization is suggested and use should be limited to the populations described in the literature (eg, DuoStim for poor prognosis patients or when expedited retrieval is essential; ERA primarily for research or selected clinical scenarios). Consider standard approaches first and document rationale when these options are pursued.

DuoStim: reserve for poor prognosis patients or time‑sensitive fertility preservation; require documentation of prior standard approaches and rationale
ERA: considered research use in many settings; document biopsy results and personalized ET timing when performed

Prior Authorization

UTx (Uterine Transplant) — Documentation and Prior Authorization Recommended

Uterine transplantation (UTx) is experimental, complex, and associated with substantial morbidity. Prior authorization is recommended before referral or scheduling. Candidates require multidisciplinary evaluation at experienced centers that meet programmatic and reporting requirements; document extensive pre‑operative testing, multidisciplinary consultations, and informed consent about risks and expected outcomes.

UTx is experimental — prior authorization strongly recommended
Document multidisciplinary consultations: gynecology, transplant surgery, psychology, immunology, anesthesiology, internal medicine, radiology
Document center qualifications, case volume, outcomes reporting and patient counseling

Billing Rule

Medication Limits and Benefit‑Check Prior to Authorization

Medication limits and benefit verification are required prior to authorization. Many plans exclude coverage for infertility injectables or sterilization reversals; some plans require pharmacy benefit review by Specialty Pharmacy Guideline Management. Verify the member’s benefit design for drug versus medical benefit coverage, plan‑specific exclusions, quantity limits, and brand‑step requirements (eg, Follistim AQ requires trial/failure of Gonal‑F per brand‑step policy).

Check if injectables are covered under the pharmacy or medical benefit and whether Specialty Pharmacy review is required
Dose/vial limits and standard limits are specified in the Appendix (eg, per‑28 day vial/cartridge limits)
Brand‑step: Follistim AQ covered only after contraindication/intolerance/ineffective response to Gonal‑F

Documentation Required

ICSI Coverage Conditions

ICSI is medically necessary in defined circumstances (eg, azoospermia/oligospermia, severe semen deficits, fertilization of frozen oocytes, iatrogenic infertility). If severe male factor infertility has been previously documented and then normalized after varicocelectomy, ICSI is considered not medically necessary. Document prior semen analyses and treatments.

ICSI indications: azoospermia, severe sperm deficits, frozen oocyte fertilization, iatrogenic infertility due to cancer therapies
If prior severe male‑factor resolved by varicocelectomy and semen normalizes, ICSI is not medically necessary

Note

Operational Note — Authorization May Be Plan‑Specific

Some areas of this section describe prior authorization operational details or code listings only in the CPB code tables and appendices. Not every specific authorization requirement is enumerated here — always verify plan‑specific prior authorization rules during benefit check.

When authorization requirements are not specified in the CPB, use benefit verification tools or contact Aetna for plan‑specific rules
CPBs are a guide and do not replace plan contract language

Denial Risk

Plan Exclusions, Coding‑Based Denial Risk, and Not‑Covered Codes

Plan exclusions and coding can trigger denials. Certain CPT/HCPCS/ICD‑10 codes are explicitly listed as not covered or limited for indications in this bulletin. Use correct diagnosis and procedure coding; avoid codes listed as not covered for CPB indications to reduce denial risk.

Review CPB code lists for not‑covered codes and ICD‑10 exclusions
Examples of HCPCS/CPT code groups and HCPCS storage/monitoring codes: S4027, S4040, S4042
Coding errors or use of excluded ICD‑10 codes may lead to denial

Denial Risk

IVM Considered Investigational — Prior Authorization/Research Setting

In‑vitro maturation (IVM) and cryopreservation of immature oocytes are considered investigational/experimental. These procedures should only be performed in specialized centers under research protocols and will generally require prior authorization and informed‑consent documentation.

IVM: experimental — limit to specialized centers and research settings
Document patient counseling regarding lower implantation/pregnancy rates compared with standard IVF

Documentation Required

Contraindications May Preclude Coverage — Document FDA Label Considerations

Contraindications and FDA boxed warnings for reproductive drugs must be checked and documented prior to prescribing. FDA‑label contraindications (eg, hypersensitivity, primary gonadal failure, tumors, pregnancy when applicable) may preclude coverage or use and should be addressed in the medical record submitted for authorization.

Review FDA contraindications/warnings for follitropins, menotropins, hCG preparations prior to administration
Document clinical rationale when dispensing agents with label warnings and monitor for OHSS and other listed risks

Prior Authorization

DuoStim — Restricted Use and Prior Authorization Considerations

DuoStim should be considered primarily for poor‑prognosis patients or when time is critical. It is a later‑line or expedited option after standard stimulation cycles have been tried or when rapid fertility preservation is needed; prior authorization and clear documentation of prior treatments and rationale are recommended.

DuoStim: apply only to poor prognosis patients or time‑sensitive cases; freeze‑all mandatory and require documentation of prior standard approaches
No RCTs or cost‑effectiveness data are yet definitive — document shared decision making

Documentation Required

ERA — Research Use Recommended; Documentation Required

ERA testing remains of uncertain routine benefit; many sources recommend use primarily in research or select clinical contexts. When ERA is performed, submit ERA biopsy reports and documentation of personalized embryo transfer timing and rationale with authorization requests.

ERA documentation elements to include: biopsy result, receptive/non‑receptive result, personalized ET timing, indication (eg, recurrent implantation failure)
Routine use of ERA in unselected patients is not broadly supported — consider research protocol or select indications

Documentation Required

CFTR Testing and Counseling — Documentation Required

For congenital bilateral absence of the vas deferens (CBAVD) and related scenarios, CFTR genetic testing and counseling for the patient and partner should be documented when indicated. Semen fructose and other diagnostic tests and counseling should also be recorded.

Document CFTR testing for man with CBAVD and testing/counseling of partner
Record semen fructose and low volume/absent vas deferens findings and genetic counseling notes

Denial Risk

Experimental Status May Trigger Denial — Prior Authorization and Documentation Recommended

Experimental procedures (eg, many add‑ons, UTx, IVM, novel genetic tests without established clinical utility) may lead to denial when billed outside approved research protocols or without prior authorization. Clearly document indication, prior treatments, and why approved alternatives are unsuitable.

Experimental status of UTx and other procedures often triggers denials without prior authorization and documentation
When pursuing experimental therapies, include evidence summary, informed consent, and justification for clinical use

Documentation Required

High Likelihood of COH‑IUI Futility with Specific Day‑3 Hormone Profile

Patients with specific Day‑3 hormonal profiles (FSH 10–15 mIU/ml and E2 ≥ 40 pg/ml) have a high likelihood of COH‑IUI futility. Document Day‑3 FSH and E2 when considering COH‑IUI and consider proceeding to IVF when these markers predict poor response to COH‑IUI.

Day‑3 FSH 10–15 mIU/ml and E2 ≥ 40 pg/ml: specificity and PPV for no live‑birth with COH‑IUI were high in cited trials
Document hormonal test dates and values (FSH/E2)

Billing Rule

Documentation for Storage and Monitoring Services (HCPCS Coding)

Documentation for storage and monitoring services (eg, storage of previously frozen embryos, per‑30 day embryo storage monitoring) should use appropriate HCPCS codes (eg, S4027, S4040, S4042) and include dates, consent for storage, and monitoring plan.

Use HCPCS codes S4027, S4040, S4042 for embryo storage/monitoring and include storage start/end dates and consent forms
Include monitoring documentation and inventory of cryopreserved specimens

Documentation Required

Ovarian Responsiveness Documentation Required

Ovarian responsiveness must be documented prior to ovarian stimulation: obtain an unmedicated day‑3 FSH within 12 months for age ≤35 or within 6 months for age >35. In women >40, any single FSH >19 mIU/mL indicates ovarian insufficiency. In women <40, an unmedicated day‑3 FSH <19 mIU/mL demonstrates capacity to respond.

Unmedicated day‑3 FSH timing: ≤35 years — within prior 12 months; >35 years — within prior 6 months
Document FSH values and dates in authorization package

Documentation Required

Ovarian Cyst Aspiration — Documentation of Rationale Required

Ovarian cyst aspiration prior to stimulation lacks conclusive benefit. If performed, document clinical rationale, cyst characteristics, and why conservative management was not chosen; be aware evidence does not support routine aspiration to improve live‑birth or cycle outcomes.

Document cyst size, ultrasound characteristics, rationale for aspiration, informed consent, and anesthesia/surgical notes when applicable

Documentation Required

Indication Documentation for Drugs and Procedures

Indication documentation is required for infertility medications and procedures. For drug therapies, document FDA‑approved indication, prior treatments, contraindications or intolerances to alternatives, and clinical rationale for the selected agent.

Include prior therapy trials and response, FDA‑label indication for the drug, and any contraindications to alternatives in the medical record submitted for authorization

Documentation Required

ERA — Required Documentation Elements

ERA documentation elements: include the endometrial biopsy report, ERA receptive/non‑receptive result, timing recommendations for personalized embryo transfer (pET), and clinical indication (eg, recurrent implantation failure). Submit these with authorization requests.

ERA report, date of biopsy, receptive vs non‑receptive classification, recommended pET timing, and indication for testing

Documentation Required

CFTR Testing — Documentation Required

CFTR testing documentation: when indicated (eg, CBAVD or low semen volume with absent vas), document CFTR testing results for the patient and partner, counseling provided, and any genetic counseling referrals.

Record CFTR test date, method, results, partner testing status, and documented counseling/referral notes

Documentation Required

Testing and Counseling Documentation for Male Infertility

Testing and counseling documentation for male infertility should include semen analysis results (use WHO reference values), semen fructose when vas absence suspected, counseling about genetic risks, and documentation of follow‑up plans.

Semen analysis should report WHO reference parameters (pH, concentration, morphology, volume, motility, total sperm number, vitality)
Document counseling and genetic testing when indicated (eg, CBAVD)

Documentation Required

Multidisciplinary Evaluation Documentation for Complex Interventions

Multidisciplinary evaluation documentation is required for complex procedures (eg, UTx) — include consultations from gynecology, transplant surgery, psychology, immunology, anesthesiology, internal medicine, radiology, and any other specialty involved. Document testing, psychosocial evaluation, and informed consent.

Include multidisciplinary consult notes, testing results, center capabilities, and documented informed consent in authorization requests for complex interventions

Documentation Required

Cycle Monitoring and Medication Documentation

Cycle monitoring and medication documentation: record serial ultrasounds, serum hormone values, medication types/doses/dates, response to stimulation, and any adverse events. Appendix specifies medically necessary counts of monitoring tests per cycle — use that guidance when documenting.

Document transvaginal ultrasound counts per cycle, estradiol/FSH/LH/progesterone measurements as applicable, medication name/dose/lot and administration dates
Follow Appendix laboratory and gonadotropin vial management limits when requesting authorization

Documentation Required

Semen Analysis — WHO Parameters and Repeat Testing

Semen analysis reporting should use WHO reference values and include key parameters (pH, concentration, morphology, volume, motility, total sperm number, vitality). Repeat abnormal semen analyses on at least 2 occasions ≥2 weeks apart when defining mild or severe male‑factor infertility.

Repeat abnormal sperm parameters on 2 separate occasions at least 2 weeks apart to define severity
Severe deficits: <10 million TMS unwashed or <3 million TMS washed; severe morphology <4% (Kruger strict)

Note

Bibliography and References

This section contains references and bibliographic material. Providers must consult the cited clinical literature and practice guidelines when preparing authorization requests or when considering emerging/experimental procedures.

Refer to CPB references and cited trials/guidelines when needed

Note

Provider Documentation Note and Coverage Disclaimer

Provider documentation note: CPBs are a partial description of plan benefits and do not replace plan contracts. Providers should verify member benefits, prior authorization requirements, and plan exclusions; document all clinical findings and rationale submitted for review.

Clinical Policy Bulletins do not guarantee coverage — verify contract/benefit details before proceeding
Include complete documentation to support medical necessity determinations

Definitions and Clinical Terms

Infertility definition

Infertility — duration-based definitionFailure to conceive after 12 months of frequent unprotected intercourse when female <35 years, or after 6 months when female ≥35 years

Alternate diagnostic criteriaInfertility may also be established by specified numbers of timed insemination cycles (6 cycles if <35; 3 cycles if ≥35) or by demonstration of reproductive tract disease rendering timed contact ineffective

ApplicabilityDefinition applies regardless of sexual orientation or presence of a reproductive partner; check plan/state mandates for variations

Ovarian reserve / menopause rules

Ovarian reserve / menopause rules — Day‑3 FSHWomen <40: Day‑3 unmedicated FSH must be < 19 mIU/mL in most recent test to use own eggs; Women ≥40: Day‑3 FSH must be < 19 mIU/mL in all prior tests to use own eggs

Menopause exclusionInfertility services for natural menopause in women ≥40 years are not covered because natural menopause is not considered a disease

Premature ovarian failure allowanceWomen <40 with Day‑3 FSH > 19 mIU/mL are considered to have premature ovarian failure; ART via donor oocytes considered medically necessary until age 45

Mild male-factor infertility definition

Mild male‑factor infertility definitionDefined for AI: two or more semen analyses at least two weeks apart with one or more variables below the 5th percentile (per plan/NICE guidance)

Use in AI eligibilityMeets indication for intra‑uterine or intra‑cervical insemination when present

DocumentationRepeat semen analyses are required to establish mild male‑factor infertility

ART cycle definition

ART cycle definitionAn ART cycle may be IVF (fresh embryos), IVF/frozen embryo transfer (FET), GIFT, or ZIFT

Elective single embryo transfer noteAetna may consider single fresh embryo transfer with immediate transfer of one cryopreserved embryo as part of the same IVF cycle under plan limits

Plan variationCheck benefit plan descriptions for cycle limits and ART coverage

Primary vs Secondary infertility

Primary vs Secondary infertilityPrimary infertility: couple has never achieved a pregnancy; Secondary infertility: at least one prior conception

RelevanceUsed to classify patients and guide evaluation and treatment planning

Source guidanceASRM definitions referenced in policy background

Ovarian responsiveness / diminished ovarian reserve

Ovarian responsiveness / diminished reserveNormal response: ≥3 follicles and peak estrogen ≥500 mIU/ml after stimulation; diminished reserve: peak estrogen <500 mIU/ml or <3 follicles

Assessment methodsDetermined by unmedicated Day‑3 FSH timing and thresholds plus response to gonadotropin stimulation

Implication for coverageCoverage of ovarian stimulation therapies restricted to women who demonstrate biologic capacity to respond per these criteria

Recurrent miscarriage defined

Recurrent miscarriage definitionDefined as loss of 3 or more consecutive pregnancies

Distinct from infertilityRecurrent pregnancy loss has separate evaluation and treatment considerations

Evidence noteASRM/other committee definitions referenced in policy

In vitro maturation (IVM) definition

In vitro maturation (IVM) definitionMaturation in culture of immature oocytes recovered without prior exposure to LH or hCG to induce meiotic resumption; considered experimental

RecommendationShould be limited to specialized centers and research settings until more evidence is available

Clinical implicationNot standard of care for routine infertility treatment

DuoStim definition

DuoStim definitionAn IVF approach with two stimulation/aspiration cycles within the same ovarian cycle (follicular and luteal phase stimulations) to increase oocyte yield

Primary use caseApplied mainly to poor prognosis patients or when time is critical (e.g., oncologic fertility preservation)

Evidence statusPromising observational data but lacks extensive RCT evidence; consider restricted use pending further validation

Eeva definition

Eeva definitionComputer‑automated time‑lapse embryo assessment platform producing scores predicting blastocyst development to aid embryo selection

Evidence conclusionSome studies show improved specificity for blastocyst prediction, but current evidence insufficient to support routine use for improving embryo selection

Policy stanceEeva considered investigational for routine embryo selection

DuoStim (duplicate definition)

DuoStim (duplicate)Double stimulation in follicular and luteal phases within the same cycle to retrieve two cohorts of oocytes

Clinical noteReported increases in oocyte/euploid blastocyst yield in poor‑prognosis cohorts; safety and broader efficacy require more data

RecommendationConsider only for selected patients until further RCT evidence available

ERA definition

ERA definitionEndometrial Receptivity Analysis (ERA): uses endometrial biopsy RNA with NGS and a predictor to classify endometrium as receptive or non‑receptive and guide personalized embryo transfer timing

Evidence statusMixed evidence including one RCT with per‑protocol benefits but limited ITT benefit; routine use in unselected patients not supported

Recommended useOffer ERA selectively (e.g., prior failed ET) or in research protocols with counseling

HL-VMB / LL-VMB microbiota definitions

HL‑VMB / LL‑VMB definitionsHL‑VMB: dominance by specific Lactobacillus spp. or Nugent score 0–3; LL‑VMB: otherwise — HL‑VMB was negatively associated with infertility in meta‑analysis

Evidence noteSystematic review found HL‑VMB associated with lower odds of infertility but mechanisms unclear

Clinical implicationVaginal microbiota evaluation not established as routine management option

CBAVD / CAVD definition

CBAVD / CAVD definitionCongenital bilateral (or unilateral) absence of the vas deferens often associated with CFTR mutations and male infertility

Testing recommendationTest affected man and his partner for CFTR mutations and provide counseling due to high mutation frequency and reproductive risk

Reproductive riskIf female partner is carrier, risk to offspring may be up to 25% (heterozygous father) or higher if homozygous

PICSI definition

PICSI definitionPhysiological ICSI using hyaluronan‑selected sperm; a randomized trial showed no significant improvement in term live‑birth versus standard ICSI

RecommendationWider routine use of PICSI is not recommended based on current evidence

Study sizeLarge RCT with 2,772 couples found no significant difference in term live‑birth

Absolute uterine factor infertility (AUFI) definition

Absolute uterine factor infertility (AUFI)Infertility fully attributable to uterine absence (congenital or surgical) or an anatomic/functional abnormality preventing implantation or completion of pregnancy

UTx statusUterus transplantation can restore fertility in AUFI but is experimental with substantial perioperative morbidity and high complication rates

Program requirementsCandidates require extensive multidisciplinary evaluation and counseling; inclusion/exclusion criteria remain evolving

Oocyte definition

Oocyte definitionOocyte = egg

ContextUsed in glossary and cycle descriptions throughout policy

RelevanceDistinguishes donor oocyte, autologous oocyte and cryopreserved oocyte uses

WHO classification of ovulatory disorders

WHO classification of ovulatory disordersGroup I: hypothalamic pituitary failure; Group II: hypothalamic pituitary dysfunction (predominantly PCOS); Group III: ovarian failure

Clinical applicationGuides selection of ovulation induction strategies (e.g., CC, metformin, gonadotropins)

SourceWHO classification referenced in policy appendix

Embryo quality (reasonable/grade B) definition

Embryo quality (reasonable/grade B)An embryo with less than 50% fragmentation is considered reasonable quality (grade B equivalent)

UseApplied when assessing embryo transfer decisions and cryopreservation candidacy

SourcePolicy appendix definitions

Poor fertilization rate definition

Poor fertilization rate definitionIVF cycles resulting in < 50% fertilization are considered poor

ImplicationMay trigger consideration of ICSI or laboratory/sperm evaluation interventions

SourcePolicy appendix definitions

Embryo Quality (ART) duplicate definition

Embryo Quality / Fertilization Rate (duplicate definitions)Embryo reasonable quality: <50% fragmentation; Poor IVF fertilization: <50% fertilization

Clinical relevanceDefinitions used to classify cycle outcomes and guide next‑step management

SourcePolicy appendix

Fertilization Rate (IVF) duplicate

Fertilization Rate (IVF) duplicateFertilization rates <50% are considered poor in IVF cycles

ConsequencePoor fertilization may justify ICSI or alternative strategies

SourceAppendix definitions

Ovarian Reserve (response to gonadotropin stimulation)

Ovarian Reserve (response to gonadotropin stimulation)Normal: ≥3 follicles and peak estrogen >500 mIU/ml after stimulation; Diminished: peak estrogen <500 mIU/ml or <3 mature follicles

Use in policyDefines expected response and criteria for considering alternative approaches (donor oocyte, etc.)

SourcePolicy appendix definitions

Severe semen quantity/quality definitions

Severe semen quantity definitionUnwashed TMS <10 million per ejaculate or washed TMS <3 million (on two occasions ≥2 weeks apart) defines severe quantity deficit

Severe semen quality definitionKruger strict morphology <4% normal forms defines severe quality deficit

ICSI exceptionIf sperm normalizes after varicocelectomy, ICSI may be considered not medically necessary

WHO semen reference values

WHO semen reference values (key thresholds)pH ≥ 7.2; sperm concentration ≥15 million/ml; morphology ≥4% normal forms; semen volume ≥1.5 ml; total motility ≥40% (or ≥32% progressive); total sperm number ≥39 million; vitality ≥58% live

UseReference values for reporting and interpreting semen analyses in policy

DocumentationSevere deficits require confirmation on two occasions at least 2 weeks apart

Endometriosis surgical staging (ASRM)

Endometriosis surgical staging (ASRM) — overviewStages I–IV: I minimal (superficial lesions ± few filmy adhesions); II mild (some deep lesions in cul‑de‑sac); III moderate (endometriomas + more adhesions); IV severe (large endometriomas, extensive adhesions)

Clinical relevanceStaging informs surgical and ART treatment decisions

SourceASRM revised classification as presented in policy appendix

Infertility definitions and committee opinions

Referenced definitions and committee opinionsASRM Practice Committee and related committee opinions define infertility and recurrent pregnancy loss referenced in policy

UsePolicy aligns definitions with cited guideline documents; see references for full text

Citation notePractice Committee documents cited in references section

Clinical Policy Bulletin

Clinical Policy Bulletin disclaimerClinical Policy Bulletins are developed to assist in administering plan benefits and do not constitute offers of coverage or medical advice

Provider responsibilityProviders must verify specific plan benefit documents for coverage determinations

Effective/Review datesPolicy effective date 05/20/1999; last review 02/15/2024; next review 07/25/2024

OpenPayer

Infertility

Coverage Criteria and Medical Necessity

Applicable Codes and Key Clinical Thresholds

Precertification, Prior Authorization, and Documentation Requirements

Background and Evidence Context

Definitions and Clinical Terms

Policy Dates and Revision Notes