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ModifiedAmbetter NevadaPolicy CP.MP.55

Assisted Reproductive Technology (ART) Coverage Criteria

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Defines medical necessity, covered services, and exclusions for assisted reproductive technologies (ART) for members whose benefit plans include infertility coverage. Applies to clinical treatments and laboratory procedures handling gametes and embryos for establishing pregnancy.

Policy Summary

PayerAmbetter Nevada

PolicyAssisted Reproductive Technology (ART) Coverage Criteria

Policy CodePolicy CP.MP.55

Change TypeCriteria clarifications and structural editsICSI indications revisedFET added to description

Effective Date

Next Review Date

Key ActionObtain prior authorization per the member's benefit plan before providing listed infertility services.

SourceLink

POLICY UPDATE CHANGES

Frozen Embryo Transfer (FET) added under Description with no impact to criteria.

ICSI indications clarified to include patients with previously failed fertilization and those with very low sperm concentration or motility; counseling regarding outcomes and small potential neonatal risks recommended.

Numerous eligibility and procedural criteria reorganized and clarified across sections (examples: embryo transfer limits, updated fertility indications, added FET and oocyte in vitro maturation references).

AddedFET status

10+Listed procedure types

~30Codes listed

43+References

IncludedMedicaid/Medicare notes

Coverage Criteria for Assisted Reproductive Technology

Basic criteria

Covered when ALL of the following basic criteria are met:

Basic criteria: 1. No untreatable anatomic cause of infertility and modifiable causes of infertility have been considered and addressed when possible.

Basic criteria: 2. Documented inability to conceive during a period of cycles exposed to sperm: 12 months for members with female reproductive systems < 35 years of age, or 6 months for those ≥ 35 years of age.

Basic criteria: 3. For members with female reproductive systems ≥ 40 years attempting conception 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's own oocytes a viable strategy.

Basic criteria:

Policy Summary

PayerAmbetter Nevada

PolicyAssisted Reproductive Technology (ART) Coverage Criteria

Policy CodePolicy CP.MP.55

Change TypeCriteria clarifications and structural editsICSI indications revisedFET added to description

Effective Date

Next Review Date

Key ActionObtain prior authorization per the member's benefit plan before providing listed infertility services.

SourceLink

On This Page

Treatment-specific criteria

Treatment-specific covered indications — the requested treatment is covered when the listed criteria for that treatment are met:

Artificial Insemination (ICI/IUI): Unilateral or bilateral tubal patency, and one of: mild male reproductive system factor infertility; cervical factors (e.g., stenosis, chronic cervicitis); ovulatory dysfunction treated with medications (e.g., clomiphene); unexplained infertility; sperm antibodies; endometriosis; use of cryopreserved sperm obtained for fertility preservation prior to gonadotoxic treatment; or situations that waive the timing requirement such as inability to have intercourse due to a physical disability or psychosexual problem, HIV-positive partner undergoing sperm washing, or single persons using donor sperm.

Some listed factors waive the usual 6–12 month infertility timing requirement.

In Vitro Fertilization with Embryo Transfer (IVF-ET): Meets one of: bilateral tubal absence/obstruction (not due to voluntary sterilization); endometriosis-associated infertility that failed treatment; severe male reproductive system infertility failing conservative treatments (sperm concentration <10 million/mL and/or normal morphology ≤1% by Krüger or ≤5% by WHO); prior IVF with failed or poor fertilization; unexplained infertility after failure of ≥3 IUI cycles with oral agents; high response to a medicated IUI cycle (both estradiol >1000 pg/mL AND production of ≥3 follicles ≥16 mm or 4–8 follicles >14 mm) requiring conversion to IVF; utilization of cryopreserved gametes/oocytes/embryos obtained for fertility preservation; or inadequate number of frozen embryos from prior IVF (fewer than 3 if age <35; fewer than 4 if age ≥35).

Refer to Table 1 for embryo transfer guidance and ASRM limits.

Frozen Embryo Transfer (FET): Meets both: (a) number of embryos to transfer per attempt meets Table 1 requirements; and (b) frozen embryos must be used prior to authorization of additional IVF cycles in specified circumstances (e.g., <35 with at least three embryos available for transfer; ≥35 with at least four embryos available for transfer), except when member continues to meet infertility diagnosis criteria.

See FET-specific embryo availability thresholds in policy.

GIFT/ZIFT: Member has at least one patent fallopian tube, AND one of: utilization of cryopreserved gametes/embryos obtained for fertility preservation, or unexplained infertility with failure of IUI (for <38 years: failure of 3 IUI cycles with oral agents; for ages 38–42: failure of at least 1 IUI cycle); AND justification that GIFT/ZIFT is preferable to standard IVF.

Intracytoplasmic Sperm Injection (ICSI): Meets one of: fewer than two million motile spermatozoa per ejaculate; anti-sperm antibodies contributing to infertility; prior or repeated fertilization failure with standard IVF (<50% fertilization); washed sperm limited in number/quality; male tract obstruction not amenable to repair requiring MESA/TESE; abnormal sperm morphology (≤1% normal forms by Krüger or ≤5% by WHO); specific sperm defects impairing sperm-oocyte interaction; fertilization of previously frozen oocytes or oocytes that underwent in vitro maturation; utilization of cryopreserved gametes for fertility preservation; HIV or hepatitis-discordant couples; need for PGT-M where contamination from other sperm must be avoided; selected female infertility with oocyte/zona anomalies.

Policy recommends counseling regarding outcomes and small potential neonatal risks for ICSI.

Donor egg/sperm and TESE/MESA: Donor egg covered for indications including congenital or surgical absence of ovaries, primary ovarian insufficiency, diminished ovarian reserve, ovarian failure after radiation/chemotherapy, prior failed IVF in those >40, gonadal dysgenesis, high genetic transmission risk, or hypergonadotropic hypogonadism. TESE/micro-TESE/epididymal extraction covered for obstructive or non-obstructive azoospermia. Donor sperm covered for bilateral congenital absence of vas deferens, ejaculatory dysfunction, obstructive azoospermia/severe oligozoospermia or other significant sperm abnormalities, single persons without male partner, high infectious/genetic transmission risk, prior abnormal semen analyses, prior radiation/chemotherapy effects, or failure of ≥3 cycles of IVF/ICSI.

Selected Procedural Indications and Authorization-related criteria

Selected coverage-relevant procedural statements, clarifications, and authorization-related requirements extracted from the policy:

ICSI indications and counseling: ICSI should be available to patients with previously failed fertilization and to patients with sperm concentration and motility too low for expected success with conventional IVF; patients should be counseled regarding outcomes and small potential neonatal risks.

Supported by policy clinical discussion and references.

ZIFT clinical role: ZIFT may be considered for patients with difficult trans-cervical embryo transfer, uterine abnormalities (e.g., DES exposure), or recurrent failure with standard IVF; success rates are similar to IVF and ZIFT may be chosen when trans-cervical embryo transfer is problematic.

Prior authorization requirement: Multiple listed infertility CPT and HCPCS procedure codes require prior authorization if the service is a covered benefit; providers must obtain prior authorization per the member's benefit plan before rendering services.

See coding sections and prior authorization callouts for the specific CPT/HCPCS codes subject to prior authorization.

CPT, HCPCS and Coding Guidance

Infertility CPT Codes that Support Medical Necessity (group 1)CPT

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	Oocyte identification from follicular fluid.
89255	Preparation of embryo for transfer (any method).

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Infertility CPT Codes that Support Medical Necessity (group 2)CPT

89268	Insemination of oocytes.
89272	Extended culture of oocyte(s)/embryo(s), 4-7 days.
89280	Assisted oocyte fertilization, microtechnique, less than or equal to 10 oocytes.
89281	Assisted oocyte fertilization, microtechniques; greater than 10 oocytes..
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- implantation genetic diagnosis); less than or equal to 5 embryos.
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- implantation genetic diagnosis); greater than 5 embryos.
89337	Cryopreservation, mature oocyte(s).
89352	Thawing of cryopreserved; embryo(s).
89353	Thawing of cryopreserved; sperm/semen, each aliquot.
89356	Thawing of cryopreserved; oocytes, each aliquot

Infertility HCPCS/CMS S-codes (case rates and procedures)HCPCS

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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Severe male factor sperm concentration

Severe male factor sperm concentrationSperm concentration less than 10 million per mL

Context of useThreshold applied when severe male reproductive system infertility has failed conservative treatments and supports IVF indication

Related requirementMay be combined with other semen abnormalities (e.g., morphology/motility) to indicate ICSI or IVF pathway

Abnormal morphology thresholds (Kruger and WHO)

Kruger morphology threshold≤ 1% normal forms by Kruger criteria

WHO morphology threshold≤ 5% normal forms by WHO criteria

ApplicationAbnormal morphology thresholds used as indications for ICSI or other assisted fertilization techniques

High estradiol for IUI-to-IVF conversion

High estradiol threshold for IUI-to-IVF conversion> 1000 pg/ml

Action when threshold metMedicated IUI cycle with estradiol >1000 pg/ml should be converted to IVF

DocumentationEstradiol level must be recorded in cycle monitoring to justify conversion to IVF and prior authorization

Follicle counts for high IUI response

High IUI response — follicle criteria AProduction of at least 3 follicles ≥ 16 mm

High IUI response — follicle criteria BOr production of 4–8 follicles > 14 mm in diameter

Resulting actionMedicated IUI cycles meeting these follicle counts (with estradiol threshold) should be converted to IVF

Embryo culture days and oocyte counts

Culture duration categoriesCulture of oocyte(s)/embryo(s) noted as: less than 4 days and extended culture 4–7 days

Microtechnique stratification by oocyte countAssisted oocyte fertilization (microtechnique) coded and described as ≤10 oocytes (89280) or >10 oocytes (89281)

PGT biopsy stratificationBiopsy for PGT described separately for ≤5 embryos (89290) and >5 embryos (89291)

Coding implicationCulture days and oocyte-count stratifications map to specific CPT codes that require prior authorization when covered

Step Therapy

Step therapy per plan administrative policy

Any step therapy requirements (e.g., required sequence of conservative treatments before advanced procedures) are defined by the member's administrative plan policies; use this clinical policy as guidance but follow plan‑specific step therapy rules.

Plan administrative policies may specify step therapy sequences and prior authorization workflows.
Confirm plan‑level step therapy requirements before proceeding with higher‑level ART interventions.

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Authorization required when medical necessity criteria are met

Obtain authorization per the member's benefit plan before providing ART services. The policy makes ART medically necessary only when both the basic criteria and the applicable treatment-specific criteria are met and authorized benefits are based on the member's benefit plan contract.

Prior Authorization

Prior authorization required for listed procedure codes

Prior authorization is required for the listed CPT and HCPCS procedure codes when the service is a covered benefit. The policy provides a list of infertility CPT and HCPCS/S-codes that require prior authorization if covered.

Prior Authorization

Prior authorization required per plan administrative rules

Obtain prior authorization in accordance with plan rules: the policy serves as a medical necessity guide and standard Health Plan administrative procedures require providers to secure authorization per the member's plan before services are rendered.

Step Therapy

Document failure of prior, less invasive therapies when required

Some treatment pathways require documented failure of less invasive therapies before advancing. For example, IVF eligibility can require failure of at least three IUI cycles for unexplained infertility or specified failed IUI counts for GIFT/ZIFT depending on age.

IVF: unexplained infertility requires failure of ≥3 IUI cycles with oral agents.
GIFT/ZIFT: <38 years requires failure of 3 IUI cycles; 38–42 years requires failure of at least 1 IUI cycle.

Note

Step Therapy

Step therapy requirements governed by plan administrative policy

The policy is a guideline; any step therapy requirements are defined by the member's plan administrative policies. Use this clinical policy to inform medical necessity determinations but verify plan-level step therapy rules.

Documentation Required

Required clinical documentation to support authorization

Maintain clinical documentation that supports medical necessity: include infertility duration (12 months if <35; 6 months if ≥35), assessment of ovarian reserve and, for those ≥40 using own oocytes, prior treatment and response, as well as condition-specific evidence such as semen analysis and tubal patency when relevant.

Infertility timing: 12 months (<35) or 6 months (≥35).
For ≥40 using own oocytes: document ovarian reserve, prior treatments and responses.
Treatment-specific evidence: semen analysis results, tubal patency, failed IUI cycles, etc.

Documentation Required

Align documentation with plan and regulatory requirements

Ensure documentation and submissions comply with the member's plan coverage documents and applicable state or federal requirements. The policy emphasizes that providers should follow plan coverage documents and regulatory requirements when documenting medical necessity.

Note

Verify member benefit plan includes infertility/ART coverage

Confirm that the member's benefit plan includes infertility/ART coverage before providing services. The policy states services are covered only when specific coverage exists under the member/enrollee's benefit plan and refers providers to benefit guidelines for coverage limitations.

Prior Authorization

Obtain prior authorization for listed infertility services

Prior authorization is required for the infertility services listed in the policy when those services are a covered benefit; failure to obtain PA when required may lead to denial.

Denial Risk

Denial risk if services fall outside plan terms, exclusions, or limits

Coverage is subject to all terms, conditions, exclusions and limitations of the member's coverage documents; services outside plan terms, exclusions or limitations risk denial of payment.

Key Definitions

inv-30: In vitro fertilization (IVF) — definition and one-cycle scope

DefinitionFertilization of an egg with sperm in a laboratory with subsequent embryo transfer to the uterus

One-cycle scopeOne IVF-ET cycle includes ovarian stimulation and monitoring, oocyte retrieval, sperm preparation/capacitation, and embryo transfer (including frozen embryo transfer)

Timing of embryo transferEmbryo transfer (including FET) may occur any time between one to six days after egg retrieval, or after cryopreservation in FET

inv-31: GIFT — Gamete intra-fallopian transfer definition

DefinitionGamete intra-fallopian transfer (GIFT) — laparoscopic aspiration of oocytes; oocytes are mixed with sperm and transferred to the fallopian tube via catheter

Indications/contextMay be chosen for religious/personal reasons or after failed donor insemination; requires laparoscopy and at least one patent tube

Success ratesSuccess rates are similar to those undergoing IVF

inv-32: ZIFT — Zygote intra-fallopian transfer definition (placement of zygotes/embryos into fallopian tube)

DefinitionZygote intra-fallopian transfer (ZIFT) — placement of fertilized eggs (zygotes) or embryos into the fallopian tube, requiring laparoscopy

Clinical roleMay be considered for difficult trans-cervical embryo transfer, uterine abnormalities (e.g., DES exposure), or recurrent IVF failure

Success comparisonOverall success rates are similar to IVF

inv-33: ICSI — Intracytoplasmic sperm injection definition and indications

DefinitionIntracytoplasmic sperm injection (ICSI) — injection of a single sperm into the egg in the laboratory to achieve fertilization

IndicationsIndicated for previously failed fertilization, very low sperm concentration or motility, antisperm antibodies, prior fertilization failure (<50%), washed sperm limited in number/quality, and abnormal morphology (Kruger ≤1% or WHO ≤5%)

Counseling notePatients should be counseled regarding outcomes and small potential neonatal risks associated with ICSI

inv-34: ZIFT (duplicate inventory entry) — alternate ZIFT definition preserved

Alternate definition preservedZygote Intra-Fallopian Transfer (ZIFT) — placement of fertilized eggs (zygotes) or embryos into the fallopian tube typically via laparoscopy

NoteEntry preserved as alternate wording consistent with main ZIFT definition and clinical use for difficult trans-cervical transfers

inv-35: ICSI (duplicate inventory entry) — laboratory microinjection definition preserved

Alternate wordingICSI — laboratory microinjection of sperm into an egg to achieve fertilization, followed by embryo transfer or cryopreservation

Indication overlapICSI indications include severe male factor, prior fertilization failure, specific sperm defects, and use with cryopreserved/IVM oocytes

inv-36: Infertility definitions — infertility and recurrent pregnancy loss informed by ASRM guidance

Infertility definition by ageFailure to achieve pregnancy after 1 year if <35 years, after 6 months if ≥35 years, or more immediately if age 40 and over

Recurrent pregnancy loss and terminologyDefinitions and related terminology are informed by ASRM committee opinions and guideline documents referenced in the policy

Use of guidanceASRM practice committee documents and related guidelines inform infertility and recurrent pregnancy loss definitions used in the policy

Assisted Reproductive Technology (ART) Coverage Criteria

Sign up for Ambetter Nevada Policy CP.MP.55 alerts

Coverage Criteria for Assisted Reproductive Technology

CPT, HCPCS and Coding Guidance

Provider Actions, Prior Authorization and Documentation

Background on Assisted Reproductive Technology

Key Definitions