Arizona Complete Health ART Coverage Update

Coverage and Medical Necessity Criteria for ART

General medical necessity (Basic criteria)

Covered when ALL of the following are met

Basic ART coverage prerequisites: 1) There is no untreatable anatomic cause of infertility and modifiable causes of infertility have been considered and modified if possible; 2) Documentation of inability to conceive during a period of 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 ≥ age 40 attempting conception using their own oocytes, documentation that the treating provider has evaluated age, infertility risk factors, 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.

Refer to benefit plan for coverage limits.

Artificial insemination (IUI/ICI) criteria

Covered when ALL of the following are met

IUI/ICI prerequisites: 1) Unilateral or bilateral tubal patency; AND 2) One of: mild male factor infertility; cervical factors (e.g., stenosis, chronic cervicitis); ovulatory dysfunction treated with medications (eg, clomiphene); unexplained infertility; sperm antibodies; endometriosis; utilization of cryopreserved sperm obtained for fertility preservation prior to non-elective treatments likely to cause infertility; unable to or very difficult to have vaginal intercourse due to physical disability or psychosexual problem (using partner or donor sperm); couples with a male partner who is HIV positive or with retrograde ejaculation undergoing sperm washing; single females without male partner using donor sperm.

Certain situations (e.g., disability, HIV-discordant couples, donor sperm use) waive the duration requirement in basic criteria I.A.2.

IVF-ET criteria

Covered when ANY one of the following is met

IVF indications list: a) Barrier to fertilization such as bilateral fallopian tube absence or obstruction due to prior tubal disease (not voluntary sterilization) or endometriosis-associated infertility that failed interventions; b) Severe male factor infertility that failed conservative treatments (sperm concentration <10 million/mL and/or morphology ≤1% Krüger/≤5% WHO); c) Prior IVF cycle with failed or poor fertilization of eggs; d) Unexplained infertility after failure of at least three cycles of IUI with oral agents (eg, clomiphene or letrozole); e) High response to a medicated cycle intended for IUI meeting BOTH: estradiol >1000 pg/mL AND production of at least three follicles ≥16 mm or four to eight follicles >14 mm (conversion to IVF); f) Utilization of cryopreserved sperm and an oocyte or embryo(s) obtained for fertility preservation prior to non-elective treatment likely to cause infertility; g) Inadequate number of frozen embryos available for transfer from a prior IVF cycle (fewer than 3 for female <35 years, or fewer than 4 for female ≥35 years).

Frozen Embryo Transfer (FET) criteria

Covered when ALL of the following are met

FET prerequisites: 1) Number of embryos to transfer per attempt meets the requirements in ASRM Table 1; AND 2) Frozen embryos must be used prior to authorization of additional IVF cycles except when continuing infertility applies or when utilization is for fertility preservation (exceptions defined by available embryo counts: ≥3 embryos available for transfer for those <35, ≥4 for those ≥35).

If member/enrollee continues with diagnosis of infertility, FET with fewer than these embryo counts is considered medically necessary.

GIFT/ZIFT criteria

Covered when ALL of the following are met

GIFT/ZIFT prerequisites: 1) Member/enrollee has at least one patent fallopian tube; AND 2) One of: utilization of cryopreserved sperm and an oocyte or embryo(s) for fertility preservation prior to non-elective treatment likely to cause infertility; OR unexplained infertility with failed IUI cycles defined by age (for female reproductive system <38 years: failure of 3 IUI cycles with oral agents; age 38–42: failure of at least 1 IUI cycle); AND 3) Justification that GIFT/ZIFT is preferable to standard IVF.

ZIFT/GIFT require laparoscopy for tubal placement and may be considered for difficult transcervical transfer or recurrent IVF transfer failure.

ICSI criteria

Covered when ANY one of the following is 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 or quality; e) Obstruction of the male reproductive tract not amenable to repair necessitating MESA/TESE; f) Abnormal morphology (≤1% by Kruger; ≤5% by WHO); g) Specific sperm defects impairing sperm-oocyte interaction; h) Fertilization of previously frozen or in vitro matured oocytes; i) Utilization of cryopreserved sperm and/or oocytes for fertility preservation prior to non-elective treatment; j) HIV or hepatitis-discordant couples; k) Need for PGT-M in settings requiring absence of extraneous DNA contamination; l) Selected female infertility with oocyte or zona pellucida anomalies.

ICSI should be available for prior fertilization failure or when sperm parameters preclude success with conventional IVF; counsel patients regarding outcomes and small potential neonatal risks.

Donor gametes, TESE, and cryopreservation

Covered when specified clinical indications are met

Donor egg indications: Donor egg cycles for members/enrollees with a female reproductive system are covered when one of the following applies: congenital or surgical absence of ovaries; primary ovarian insufficiency (menopause before age 40); diminished ovarian reserve; ovarian failure after radiation or chemotherapy; previously failed IVF in those >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 applies: partner with male reproductive system has bilateral congenital absence of the vas deferens; ejaculatory dysfunction; obstructive azoospermia, severe oligozoospermia, or other significant sperm/seminal abnormalities; absence of a male partner; high infectious or genetic transmission risk; non-obstructive azoospermia confirmed by MESA/TESA; red-cell antigen incompatibility with history of affected infant; previous radiation/chemotherapy causing abnormal semen; two abnormal semen analyses ≥30 days apart; or failure of at least three cycles of IVF or ICSI.

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

General coverage criteria and modality-specific indications

Covered when meeting ART-specific clinical indications and prior authorization requirements (summary of the sections and major indications present in this excerpt):

ART Modalities Described: Includes IVF, ICSI, ZIFT, GIFT, IUI, cryopreservation (embryo/oocyte/sperm), thawing, assisted fertilization microtechniques, embryo biopsy for PGT, and related laboratory procedures.

See coding module for CPT/HCPCS codes that require prior authorization.

ICSI Access and Counseling: ICSI should be available for patients with prior fertilization failure or sperm parameters unlikely to succeed with conventional IVF; providers should counsel patients on outcomes and small potential neonatal risks.

Clinical description supports indications in ICSI criteria.

ZIFT/GIFT Role: ZIFT (and GIFT) may be considered for patients with difficult transcervical embryo transfer, uterine abnormalities, or recurrent IVF transfer failure and require laparoscopy for tubal placement.

Policy includes HCPCS case rate codes for these procedures.

The following services are expressly excluded from coverage and considered non-covered under this policy: surrogacy; reversal of voluntary sterilization; any experimental infertility procedure; and commercially available over-the-counter home test kits (including but not limited to ovulation prediction and pregnancy test kits). Additional exclusions include infertility treatment required because of prior voluntary sterilization or unsuccessful sterilization reversal, partner infertility services when the partner is not an enrollee unless mandated by benefits, sex selection and chromosomal studies of donor gametes or eggs, and age-based exclusions for menopausal females as detailed in the policy (e.g., those ≤54 and those >55 with specified exceptions).

This policy reflects multiple editorial and substantive revisions to criteria language and formatting. Revisions removed certain prior notes and reorganized subcriteria (for example, deletion of some prior I.B. items and edits to embryo cryopreservation references), clarified provider evaluation language (including additions to clomiphene citrate challenge test wording), updated embryo transfer guidance and Table 1 placement, and reformatted IUI/IVF/FET sections to align with other Centene policies. These updates changed wording, added and removed items across IUI/IVF/FET subcriteria and reflowed notes to integrate guidance into the criteria themselves rather than separate notes.

Coverage under this policy is determined in the context of the member's benefit documents. All services described are subject to the terms, conditions, exclusions and limitations of the member's Evidence of Coverage, certificate of coverage, policy or contract of insurance, and applicable state and federal requirements. This policy provides medical necessity guidance but does not guarantee payment when the benefit or contract excludes the service. Providers should verify benefit eligibility and applicable plan limitations prior to requesting authorization.

Restating the policy position: Assisted reproductive technology (ART) is not medically necessary for any experimental infertility procedure, for services provided in support of surrogacy, or for reversal of voluntary sterilization. The policy also identifies commercially available over-the-counter home test kits as non-covered. These exclusions are explicit in the policy's not-medically-necessary list and apply unless otherwise required by contract or mandate.

Some policy excerpts in the revision history do not restate the full list of not medically necessary items verbatim; earlier language referencing exclusions such as 'experimental infertility procedures' and surrogacy was edited or relocated during reformatting. Where an explicit 'not medically necessary' statement is absent in a given excerpt, the full exclusion list in the current policy text (see sections detailing non-covered services) remains the authoritative source for coverage determinations. Refer to the updated policy sections for the complete exclusion wording.

Relevant CPT/HCPCS Codes and Clinical Thresholds

Coding implications (section present)mixed

No codes listed

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

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)CPTCovered

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

HCPCS/S codes for ART case rates and proceduresHCPCSCovered

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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Estradiol and follicle response threshold for conversion to IVF

Estradiol thresholdEstradiol level >1000 pg/mL

Follicle response — option AProduction of at least three follicles ≥16 mm

Follicle response — option BProduction of four to eight follicles >14 mm in diameter

Embryo availability threshold before additional IVF

Threshold for female <35 yearsFewer than 3 frozen embryos available for transfer justifies additional IVF authorization

Threshold for female ≥35 years

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Benefit Coverage & Prior Authorization

Authorized infertility benefits are covered only when the member's benefit plan provides coverage. Prior authorization (PA) is required for the infertility and ART services listed below if those services are a covered benefit under the member's contract. Providers must verify the member's benefit plan, contract limitations, and the effective date of this clinical policy prior to requesting or performing services.

PA is required only when the service is a covered benefit per the member's contract.
Providers should confirm the policy effective date and any plan-specific PA procedures prior to submission.

Documentation Required

Required Clinical Documentation

Providers must submit clinical documentation that supports medical necessity for the requested service. Documentation should include duration of infertility, prior treatments and responses, ovarian reserve evaluation, and any supporting diagnostic test results or procedure reports. Records should demonstrate that basic and treatment-specific policy criteria have been met, including any required prior treatment failures or clinical thresholds.

Background on Assisted Reproductive Technologies

Assisted reproductive technologies (ART) encompass medical and laboratory procedures that manipulate gametes and embryos to achieve pregnancy. Common modalities include intrauterine or intracervical insemination (IUI/ICI), in vitro fertilization with embryo transfer (IVF-ET), intracytoplasmic sperm injection (ICSI), GIFT/ZIFT, and cryopreservation of sperm, oocytes and embryos. Infertility is clinically defined by duration without conception that varies by age (for example, generally 12 months of unprotected intercourse for those under 35 and 6 months for those ≥35), and clinical decision-making for ART requires evaluation of anatomic causes, ovarian reserve, semen parameters and prior treatment responses. These clinical definitions and descriptions guide which ART modalities may be appropriate and when prior authorization and documentation are required.

Key Definitions

In vitro fertilization (IVF-ET) — definition and cycle components

DefinitionIn vitro fertilization (IVF-ET): fertilization of an egg with sperm outside the body in a laboratory with subsequent embryo transfer

Cycle componentsOne IVF-ET cycle includes ovulation stimulation and monitoring, oocyte retrieval, sperm preparation/capacitation, and embryo transfer (or cryopreservation for FET)

Timing of transferEmbryo transfer may occur one to six days after egg retrieval or after cryopreservation for FET

Gamete Intra-Fallopian Transfer (GIFT) — definition and clinical context

DefinitionGamete Intra-Fallopian Transfer (GIFT): laparoscopic aspiration of mature oocytes which are mixed with sperm and transferred to the fallopian tube via catheter

Clinical context

Policy Revision History

03/14material_change

Under basic criteria clarified that men were to be treated by a board-certified urologist; added IVF, conversion from IUI to IVF, and FET criteria; restructured sections and removed Authorization Protocols.

12/21annual_review

Annual review: references reviewed, updated and reformatted; terminology changed to 'female reproductive system'/'male reproductive system' and experimental procedure language shortened.

01/24addition

Annual review: added Frozen Embryo Transfer (FET) under Description (no impact to criteria); added new criteria including oocytes undergoing in vitro maturation and expanded male-factor and ejaculatory dysfunction criteria.

OpenPayer

Assisted Reproductive Technology (ART) — Coverage Criteria

Coverage and Medical Necessity Criteria for ART

Relevant CPT/HCPCS Codes and Clinical Thresholds

Prior Authorization, Documentation, and Provider Responsibilities

Background on Assisted Reproductive Technologies

Key Definitions

Policy Revision History