CurrentAmbetter GeorgiaPolicy CP.MP.55

Assisted Reproductive Technology

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Defines medical necessity, coverage criteria, and exclusions for assisted reproductive technologies (IVF, IUI, ICSI, donor gametes, cryopreservation, GIFT/ZIFT, TESE/MESA, etc.) for Ambetter Georgia members when infertility benefits are included in the member's benefit plan.

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CurrentAmbetter GeorgiaPolicy CP.MP.55

Assisted Reproductive Technology

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Policy Summary

PayerAmbetter Georgia

PolicyAssisted Reproductive Technology

Policy CodePolicy CP.MP.55

Change TypeNo material changes

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain prior authorization for IVF cycles and frozen embryo transfers when meeting the policy's criteria and document infertility duration and prior treatments per age-based definitions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-06-01Effective date

<2MICSI threshold

IncludedAge guidance

IncludedFET

~40+Codes requiring PA

Coverage Criteria — Medical Necessity for Assisted Reproductive Technologies

Overall Medical Necessity (General and Basic Criteria)

Covered when ALL of the following are met

Basic criteria A: 1. There is no untreatable anatomic cause of infertility and modifiable causes of infertility have been considered and modified when possible; 2. Documentation of inability to conceive during 12 months of cycles exposed to sperm (including IUI), or six months for those with female reproductive systems age ≥ 35; 3. For those with female reproductive systems ≥ 40 using their own oocytes, documentation that the treating provider has evaluated age, infertility risk factors, measure of ovarian reserve, prior treatment and response, and considers use of the member/enrollee's own oocytes a viable strategy; 4. Infertility is unrelated to voluntary sterilization or failed reversal of voluntary sterilization of either partner.

Artificial Insemination (IUI/ICI) Criteria

Covered when ALL of the following are met

IUI/ICI criteria: a. Unilateral or bilateral tubal patency; AND b. One of the following indications: mild male reproductive system factor infertility; cervical factors (e.g., stenosis, chronic cervicitis); ovulatory dysfunction treated with medications such as clomiphene; unexplained infertility; sperm antibodies; endometriosis; utilization of cryopreserved sperm obtained for fertility preservation before non-elective treatment likely to cause infertility; OR c. One of the following exception circumstances that waive the duration requirement: 1) Unable to or would find it very difficult to have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem and are using partner or donor sperm; 2) Couples in which the partner with a male reproductive system is HIV positive or has retrograde ejaculation and undergoing sperm washing; 3) Members/enrollees with a female reproductive system without a partner with a male reproductive system who are using donor sperm.

In Vitro Fertilization with Embryo Transfer (IVF-ET) Criteria

Covered when ANY of the following are met

IVF indications group a-e: a. Barrier to fertilization: i. bilateral fallopian tube absence or obstruction due to prior tubal disease (not voluntary sterilization); ii. endometriosis-associated infertility after failed endometriosis treatment interventions; iii. severe male reproductive system infertility that has failed conservative treatments (sperm concentration <10 million/mL and/or morphology ≤1% Krüger/≤5% WHO); iv. prior IVF cycle with failed or poor fertilization; b. Unexplained infertility after failure of at least three cycles of IUI with oral agents (e.g., clomiphene or letrozole); c. High response to a medicated IUI cycle intended for IUI, defined by BOTH: i. estradiol > 1000 pg/mL; AND ii. production of ≥3 follicles ≥16 mm or 4–8 follicles >14 mm, and the cycle will be converted to IVF; d. Utilization of cryopreserved sperm and an oocyte or embryo(s) obtained for fertility preservation before non-elective treatment likely to cause infertility; e. Inadequate number of frozen embryos available for transfer from a prior IVF cycle: fewer than 3 for age <35, or fewer than 4 for age ≥35 (see Table 1 for embryo transfer guidance).

Frozen Embryo Transfer (FET) Criteria

Covered when ALL of the following are met

FET criteria: a. Number of embryos to transfer per attempt at conception meets the requirements in Table 1; AND b. Frozen embryos must be used prior to authorization of additional IVF cycles in the following circumstances: i. female reproductive system <35 years with at least three embryos available for transfer; ii. female reproductive system ≥35 years with at least four embryos available for transfer; iii. utilization of cryopreserved embryo(s) obtained for fertility preservation before non-elective treatment likely to cause infertility. Note: If member/enrollee continues with the diagnosis of infertility, FET with fewer than these numbers of embryos available for transfer is considered medically necessary.

GIFT/ZIFT Criteria

Covered when ALL of the following are met

GIFT/ZIFT criteria: a. Member/enrollee has at least one patent fallopian tube; AND b. One of the following: i. utilization of cryopreserved sperm and an oocyte or embryo(s) obtained for fertility preservation before non-elective treatment likely to cause infertility; OR ii. unexplained infertility with failure of three cycles of IUI with oral agents for those <38 years, or failure of at least one cycle of IUI with oral agents for those age 38–42; AND c. Justification that GIFT/ZIFT is preferable to standard IVF.

Intracytoplasmic Sperm Injection (ICSI) Criteria

Covered when ANY of the following are met

ICSI indications: a. Fewer than two million motile spermatozoa per ejaculate; b. Anti-sperm antibodies contributing to infertility; c. Prior or repeated fertilization failure with standard IVF protocols (<50% fertilization); d. Washed sperm limited in number and quality; e. Obstruction of the male reproductive tract not amenable to repair necessitating MESA or TESE; f. Abnormal morphology (≤1% normal forms by Kruger; ≤5% normal forms by WHO); g. Specific sperm defects impairing sperm–oocyte interaction; h. Fertilization of previously frozen oocytes and oocytes that have undergone in vitro maturation; i. Utilization of cryopreserved sperm and/or oocytes obtained for fertility preservation before non-elective treatment likely to cause infertility; j. HIV or hepatitis-discordant couples; k. Need for PGT-M in settings requiring absence of extraneous DNA contamination from other sperm; l. Treatment of selected female infertility such as morphologic anomalies of oocytes and/or anomalies of the zona pellucida.

Donor Egg and Donor Sperm Criteria

Covered when ANY of the following are met

Donor egg indications: Donor egg cycle for those with a female reproductive system is covered when at least one of the following is met: congenital or surgical absence of ovaries; primary ovarian insufficiency (menopause before age 40); diminished ovarian reserve; ovarian failure following radiation or chemotherapy; previously failed IVF in those age >40; gonadal dysgenesis including Turner Syndrome; high risk of transmitting a genetic disorder; hypergonadotropic hypogonadism.

Donor sperm indications: Donor sperm is covered when one of the following is met: partner with male reproductive system has bilateral congenital absence of vas deferens; ejaculatory dysfunction; obstructive azoospermia, severe oligozoospermia, or other significant sperm/seminal fluid abnormalities; single people without a male partner; high infectious disease transmission risk (e.g., HIV); high genetic transmission risk; male partner non-obstructive azoospermia confirmed via MESA/TESE; red cell antigen incompatibility with prior severely affected infant; prior radiation/chemotherapy causing abnormal semen; two abnormal semen analyses ≥30 days apart; or failure of ≥3 cycles of IVF or ICSI.

TESE/MESA and Cryopreservation

Covered when ALL of the following are met

TESE/MESA: TESE, micro-TESE and epididymal sperm extraction are covered for members with a male reproductive system with obstructive or non-obstructive azoospermia.

Cryopreservation: Short-term cryopreservation is covered for sperm and mature oocytes during the initial year: sperm short-term storage during the initial year (up to 90 days approved at a time beyond the initial year after last approved infertility treatment) for male members in active infertility treatment who underwent approved MESA or TESE; and short-term cryopreservation of mature oocytes during the initial year (up to 90 days approved at a time beyond the initial year).

Summary of criteria changes and additions (revision log)

Coverage criteria and edits (summary of revisions and additions as recorded in the review log).

documented updates: Multiple additions and clarifications to criteria I.A and I.B across revisions, including addition of IVF, conversion from IUI to IVF, inclusion of Frozen Embryo Transfer (FET), expanded indications (HIV/hepatitis-discordant couples; PGT-M needs; selected oocyte/zona anomalies), updates to age-related guidance, removal of certain prior criteria (e.g., assisted hatching, prior embryo cryopreservation wording), and other editorial and formatting changes noted in the revision history.

See full policy text and revision log for dates and detailed item-level changes.

The policy lists specific exclusions and services considered not medically necessary. Not covered are surrogacy, reversal of voluntary sterilization, and use of commercially available over-the-counter home test kits (including ovulation prediction and pregnancy test kits). The policy also excludes infertility treatment that is needed as a result of prior voluntary sterilization or unsuccessful sterilization reversal, partner infertility services when the partner is not a covered member/enrollee (unless mandated by benefits), and ART procedures considered experimental.

The revision log documents multiple editorial and criteria changes across reviews. Notable changes include removal of select prior criteria (for example, CPT code 89253 was removed from the supporting CPT code table and certain wording and numbered criteria were reorganized), the addition and clarification of Frozen Embryo Transfer (FET) in the description without changing criteria logic, and other adjustments to criteria wording, numbering, and notes. Providers should consult the full policy for exact current criterion text and logic.

When treating Medicaid members/enrollees, state Medicaid coverage provisions take precedence where they conflict with this clinical policy. Providers must refer to the applicable state Medicaid manual for any coverage provisions and follow member contract terms, federal/state requirements, and Health Plan administrative policies when requesting coverage or prior authorization.

The policy specifies that procedures considered experimental are not medically necessary and therefore excluded. It reiterates exclusions including surrogacy, reversal of voluntary sterilization, and commercially available OTC home test kits. Infertility services that result from prior voluntary sterilization or unsuccessful sterilization reversal are also not covered, and partner services for individuals who are not plan members are excluded unless coverage is required by the member's benefits.

This block provides no additional standalone criteria beyond what is covered elsewhere in the policy. Refer to the policy sections and the revision log for complete coverage criteria and exclusions, including the detailed lists of covered ART services, exclusions, and updates made during annual review cycles.

Coding — CPT, HCPCS/SART Codes and Clinical Thresholds

Infertility CPT Codes requiring prior authorization if coveredCPTCovered

58321	Artificial insemination; intra-cervical.
58322	Artificial insemination; intra-uterine.
58323	Sperm washing for artificial insemination.
58970	Follicle puncture for oocyte retrieval, any method.
58974	Embryo transfer, intrauterine.
58976	Gamete, zygote, or embryo intrafallopian tube transfer; any method.
89250	Culture of oocyte(s)/embryo(s), less than 4 days.
89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/ embryo(s).
89254	Embryo(s) oocyte identification from follicular fluid.
89255	Preparation of embryo for transfer (any method).

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1/3

HCPCS/S ART case-rate codes requiring prior authorization if coveredHCPCSCovered

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.
S4013	Complete cycle, gamete intrafallopian transfer (GIFT), case rate.
S4014	Complete cycle, zygote intrafallopian transfer (ZIFT), case rate.
S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate.
S4016	Frozen in vitro fertilization cycle, case rate.
S4017	Incomplete cycle, treatment canceled prior to stimulation, case rate.
S4018	Frozen embryo transfer procedure canceled before transfer, case rate.
S4020	In vitro fertilization procedure canceled before aspiration, case rate.
S4021	In vitro fertilization procedure canceled after aspiration, case rate.
S4022	Assisted oocyte fertilization, case rate.

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ICSI motile sperm threshold

ICSI motile sperm thresholdFewer than two million motile spermatozoa per ejaculate (< 2,000,000)

Related ICSI indications (examples)Also covered for antisperm antibodies, prior fertilization failure with standard IVF, washed sperm limited in number/quality

Reference contextICSI is indicated when sperm concentration and motility are too low to expect success with conventional IVF

High response estradiol threshold

Estradiol threshold for high responseEstradiol > 1000 pg/mL

Clinical actionHigh estradiol in a medicated IUI cycle may prompt conversion to IVF per policy criteria

Provider Actions — Authorization, Documentation, and Billing

Prior Authorization

Prior authorization required for IVF cycles and FET per policy criteria

Authorization is required for IVF cycles and for frozen embryo transfers (FET) when the member meets the policy's embryo-availability and ASRM transfer limits; frozen embryos must be used prior to authorization of additional IVF cycles in the specified embryo-availability scenarios (e.g., <35 with ≥3 embryos; ≥35 with ≥4 embryos) unless FET with fewer embryos is considered medically necessary for continued infertility.

IVF-ET and FET authorization is conditional on meeting numeric embryo availability and transfer limits (see Table 1).
FET must be used prior to authorization of additional IVF cycles when the member has the specified number of frozen embryos available.
Exception: FET with fewer embryos is medically necessary if the member continues with the diagnosis of infertility.

Prior Authorization

Prior authorization required for listed CPT codes

The CPT codes listed in the policy for infertility services require prior authorization when the service is a covered benefit by the member's plan.

Background — Overview of Assisted Reproductive Technologies

Assisted reproductive technology (ART) encompasses clinical treatments and laboratory procedures handling gametes and embryos to establish pregnancy. In vitro fertilization (IVF) typically involves ovarian stimulation, oocyte retrieval, sperm preparation, fertilization in the laboratory, and embryo transfer or cryopreservation; a single IVF cycle includes stimulation and monitoring (~8–14 days), retrieval, fertilization, and either fresh transfer or cryopreservation of embryos. GIFT and ZIFT are alternative procedures involving laparoscopic placement of gametes or zygotes into the fallopian tube and may be selected for personal or clinical reasons. Providers should document the clinical indication, prior treatments and responses, and relevant diagnostic findings when seeking authorization for ART services.

Definitions

Infertility (female reproductive system)

Infertility definition (<35)Failure to achieve pregnancy after 1 year if under age 35

Infertility definition (≥35)Failure to achieve pregnancy after 6 months if age 35 or older

Immediate evaluation age thresholdMore immediate evaluation if age 40 and over

Assisted Reproductive Technology (ART)

ART definitionClinical treatments and laboratory procedures handling human oocytes, sperm, or embryos to establish pregnancy (includes IUI, ICI, IVF-ET, GIFT, ZIFT, ICSI, FET, cryopreservation, TESE/MESA, sperm washing)

Scope notePolicy Description lists specific ART procedures covered under female reproductive system services

Revision History and Bibliography

Summary of criteria changes and additions (revision log)

Coverage criteria and edits (summary of revisions and additions as recorded in the review log).

documented updates: Multiple additions and clarifications to criteria I.A and I.B were made across revisions, including addition of IVF, conversion from IUI to IVF, FET, expanded indications (HIV/hepatitis-discordant couples, preimplantation genetic testing for monogenic disorders, selected oocyte anomalies), and changes to age-related criteria.

Full detailed criteria text not included in these chunks; see full policy for exact AND/OR logic.

2026-06-01policy_effective_dateLatest

Policy CP.MP.55 (Assisted Reproductive Technology) became effective.

Policy Summary

PayerAmbetter Georgia

PolicyAssisted Reproductive Technology

Policy CodePolicy CP.MP.55

Change TypeNo material changes

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain prior authorization for IVF cycles and frozen embryo transfers when meeting the policy's criteria and document infertility duration and prior treatments per age-based definitions.

SourceLink

On This Page

Used with follicle criteriaEstradiol >1000 pg/mL must be present together with specified follicle production to meet high-response conversion criteria

High response follicle threshold

High response follicle criteriaProduction of at least three follicles ≥16 mm OR four to eight follicles >14 mm

Clinical actionMeets part of the policy definition for conversion of a medicated IUI cycle to IVF when combined with estradiol >1000 pg/mL

Measurement timingFollicle sizes assessed during monitoring of a medicated stimulation cycle prior to conversion decision

Female reproductive system age limits

Age guidance up to 54 yearsPolicy updated to reference members with a female reproductive system who are ≤ 54 years of age and are menopausal (exceptions when using donor egg for premature ovarian failure)

Criteria for those >55 yearsA new criteria item was added regarding members with a female reproductive system who are > 55 years of age (see full policy for specifics)

Reference noteRevisions included wording changes and additions to age-related criteria across updates

Examples include CPT codes 58321, 58322, 58323, 58970, 58974, 58976, 89250–89261, 89264, 89268, 89272, 89280–89281, 89290–89291, 89337, 89352–89356.
Providers must obtain prior authorization before providing services billed with these CPT codes if the member's benefit plan covers them.

Prior Authorization

Prior authorization required for listed HCPCS/S ART codes

The HCPCS/S case-rate and procedure codes for ART cycles and related services listed in the policy require prior authorization if those services are a covered benefit under the member's plan.

Examples include S4011, S4013–S4018, S4020–S4023, S4025–S4028, S4035, S4037.
Obtain prior authorization per plan requirements before performing services billed with these HCPCS/S codes when covered.

Prior Authorization

Follow Health Plan and member benefit rules for prior authorization

Prior authorization requirements for ART services are governed by the Health Plan's administrative policies and the member's benefit documents; providers should obtain prior authorization as required by the Health Plan before providing ART services.

Authorized infertility benefits are covered based on the member/enrollee's benefit plan contract; refer to benefit guidelines for coverage limitations.
State Medicaid provisions take precedence where they conflict with this clinical policy.

Step Therapy

Step requirement: documented failure of IUI before IVF (when indicated)

IVF for unexplained infertility generally requires documented failure of prior IUI cycles: at least three IUI cycles with oral agents for most members; specified fewer IUI attempts apply in GIFT/ZIFT criteria for older age groups.

IVF indication: unexplained infertility with failure of at least three cycles of IUI with oral agents.
GIFT/ZIFT: for those <38 years, failure of three IUI cycles; for ages 38–42, failure of at least one IUI cycle.

Documentation Required

Documentation must show infertility duration, anatomic evaluation, modifiable causes, and ovarian reserve assessment

Document duration of infertility per age-based definitions, document evaluation of anatomic and modifiable causes, and provide assessment of ovarian reserve and prior treatment/response when applicable (e.g., those ≥ age 40 using own oocytes).

Infertility timeframe: 12 months if <35, six months if ≥35, or more immediate evaluation if age ≥40.
Include evaluation documentation showing no untreatable anatomic cause and that modifiable causes were considered/modified.
For members ≥40 using own oocytes, document evaluation of age, infertility risk factors, measure of ovarian reserve, prior treatment and response.

Billing Rule

Reference listed CPT and HCPCS/S codes and follow payer coding guidance

When requesting prior authorization and submitting claims, providers should reference the policy's listed CPT and HCPCS/S codes and follow payer coding guidance.

Use the policy's CPT code list for infertility services requiring prior authorization and the HCPCS/S list for case-rate ART services.
Follow Health Plan coding guidance when submitting authorization requests and claims.

Documentation Required

Adhere to member contract, state/federal requirements, and Health Plan administrative policies

Providers must follow member contract terms, applicable state and federal requirements, and Health Plan administrative policies when requesting coverage; documentation submitted must support medical necessity per this clinical policy and the member's benefit terms.

State Medicaid coverage provisions override this policy where they conflict; consult the state Medicaid manual as needed.
Coverage determinations are subject to plan terms, exclusions, and limitations in the member's coverage documents.

Denial Risk

Verify member benefit coverage to avoid denial

Coverage is subject to the member/enrollee's benefit plan terms; services not included in the member's plan may be denied.

Determine whether infertility services (including partner services) are covered under the member's benefit plan before providing services or requesting authorization.
Unauthorized or non-covered services are at risk for denial.

Denial Risk

Prior authorization required for listed infertility CPT codes to prevent denial

Infertility services described by the policy's CPT codes require prior authorization if they are a covered benefit; failure to obtain required authorization may lead to claim denial.

Prior authorization is required for the CPT codes listed in the policy when the services are covered.
Providers should secure authorization before delivering covered infertility services to mitigate denial risk.

Denial Risk

Coverage decisions depend on plan terms, exclusions, and applicable legal/regulatory requirements

Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents; providers should review plan terms and applicable regulations as these govern final coverage determinations.

Discrepancies between this clinical policy and state Medicaid provisions defer to the state Medicaid manual.
Medicare NCD/LCDs and other legal/regulatory requirements must be reviewed before applying policy criteria.

Related policiesRefer to pharmacy policy CP.PHAR.131 for medication considerations

In vitro fertilization (IVF-ET)

IVF-ET definitionFertilization of an egg with sperm outside the body in a laboratory with subsequent embryo transfer to the uterus

Cycle componentsA cycle includes ovarian stimulation and monitoring (8–14 days), oocyte retrieval, sperm preparation, and embryo transfer or cryopreservation

Embryo timingEmbryo transfer (including FET) may occur 1 to 6 days after retrieval or after cryopreservation

Gamete Intra-Fallopian Transfer (GIFT)

GIFT descriptionLaparoscopic retrieval of oocytes mixed with sperm and transferred to the fallopian tube via catheter

Indication/contextMay be chosen by patients who decline laboratory embryo creation or after failed donor insemination; success rates similar to IVF

Policy criteria linkGIFT requires at least one patent tube and justification that GIFT/ZIFT is preferable to IVF

Zygote Intra-Fallopian Transfer (ZIFT)

ZIFT descriptionPlacement of fertilized eggs (zygotes) into the fallopian tube via laparoscopy

Clinical useAnalogous to GIFT; may help with difficult transcervical transfer, uterine abnormalities, or recurrent IVF failure

Policy criteria linkZIFT requires at least one patent tube and justification that ZIFT/GIFT is preferable to IVF

Intra-Cytoplasmic Sperm Injection (ICSI)

ICSI definitionLaboratory microinjection of a sperm into an oocyte to achieve fertilization, with embryos transferred or cryopreserved

Primary usesUsed for failed fertilization with conventional IVF or severe sperm abnormalities (very low concentration/motility)

Policy linkageICSI criteria include specific sperm thresholds and situations such as need for PGT-M or use of cryopreserved gametes

Infertility / recurrent pregnancy loss definitions

Reference to ASRM definitionsPolicy references ASRM Practice Committee opinions for definitions of infertility and recurrent pregnancy loss but does not restate them in full

Guidance locationSee cited ASRM committee opinion (Fertil Steril. 2020) for formal definitions

Policy notePolicy relies on external professional society definitions where indicated

2026-01-06bibliography_update

Literature and guidance sources (UpToDate access dates and recent committee opinions) were updated and referenced in the policy's bibliography.

2021-06-01ASRM_guidance_cited

ASRM guidance on limits to the number of embryos to transfer (committee opinion) was cited in policy references.

2020-01-01ICSI_and_unexplained_infertility_references

ASRM Practice Committee opinions on ICSI for non-male factor indications and evidence-based treatments for unexplained infertility were added to references.

2014-01-01foundational_reference_added

ACOG Committee Opinion on female age-related fertility decline was included in the policy references.