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    v1.0.28
    OpenPayerPolicy UpdatesReproductive Health & FertilityArizona Complete Health ART Coverage Update | Open…
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    ModifiedArizona Complete HealthPolicy CP.MP.55

    Assisted Reproductive Technology (ART) — Coverage Criteria

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    Defines medical necessity, covered procedures, and exclusion criteria for assisted reproductive technologies for members whose benefit plans include infertility services. Applies to clinical providers and benefits administrators determining coverage for ART for eligible members/enrollees.

    Policy Summary
    PayerArizona Complete Health
    PolicyAssisted Reproductive Technology (ART) — Coverage Criteria
    Policy CodePolicy CP.MP.55
    Change TypeUpdated IUI/IVF/FET criteriaadded FET to Descriptionclarified male urology requirement
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and document infertility duration, ovarian reserve and prior treatments; use frozen embryos before authorizing additional IVF cycles when thresholds apply.
    SourceLink
    POLICY UPDATE CHANGES

    Under basic criteria, clarified that men were to be treated by board-certified urologist.

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

    Updated multiple IUI/IVF/FET criteria and reorganized sections to resemble other Centene clinical policies, including updates to embryo transfer guidance and removal of certain prior notes.

    ~10procedure categories
    12+IVF indications
    Age-basedage-based infertility def
    IncludedFET guidance added
    Annualreview cadence

    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.
    Policy Summary
    PayerArizona Complete Health
    PolicyAssisted Reproductive Technology (ART) — Coverage Criteria
    Policy CodePolicy CP.MP.55
    Change TypeUpdated IUI/IVF/FET criteriaadded FET to Descriptionclarified male urology requirement
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization and document infertility duration, ovarian reserve and prior treatments; use frozen embryos before authorizing additional IVF cycles when thresholds apply.
    SourceLink
    On This Page
    Coverage and Medical Necessity Criteria for ARTRelevant CPT/HCPCS Codes and Clinical ThresholdsPrior Authorization, Documentation, and Provider ResponsibilitiesBackground on Assisted Reproductive TechnologiesKey DefinitionsPolicy Revision History

    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.
    Cryopreservation: Short-term cryopreservation of sperm or mature oocytes is covered during the initial year (with approvals up to 90 days thereafter) for patients in active infertility treatment or for fertility preservation prior to non-elective treatments likely to cause infertility; cryopreservation of embryos referenced in policy notes and subject to revision history.

    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.

    Prior Authorization Required: Specified CPT and HCPCS codes for infertility and ART require prior authorization when they are a covered benefit; lack of authorization may result in denial.

    Providers must verify benefit coverage and follow prior authorization procedures per the member's plan.

    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
    58321Artificial insemination; intra-cervical.
    58322Artificial insemination; intra-uterine.
    58323Sperm washing for artificial insemination.
    58970Follicle puncture for oocyte retrieval, any method.
    58974Embryo transfer, intrauterine.
    58976Gamete, zygote, or embryo intrafallopian tube transfer; any method.
    89250Culture of oocyte(s)/embryo(s), less than 4 days.
    89251Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/ embryo(s).
    89254Oocyte identification from follicular fluid.
    89255Preparation of embryo for transfer (any method).
    1–10 of 16
    1/2
    Infertility CPT Codes that Support Medical Necessity (group 2)CPTCovered
    89268Insemination of oocytes.
    89272Extended culture of oocyte(s)/embryo(s), 4-7 days.
    89280Assisted oocyte fertilization, microtechnique, less than or equal to 10 oocytes.
    89281Assisted oocyte fertilization, microtechniques; greater than 10 oocytes..
    89290Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- implantation genetic diagnosis); less than or equal to 5 embryos.
    89291Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- implantation genetic diagnosis); greater than 5 embryos.
    89337Cryopreservation, mature oocyte(s).
    89352Thawing of cryopreserved; embryo(s).
    89353Thawing of cryopreserved; sperm/semen, each aliquot.
    89356Thawing of cryopreserved; oocytes, each aliquot
    HCPCS/S codes for ART case rates and proceduresHCPCSCovered
    S4011In 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.
    S4013Complete cycle, gamete intrafallopian transfer (GIFT), case rate.
    S4014Complete cycle, zygote intrafallopian transfer (ZIFT), case rate.
    S4015Complete in vitro fertilization cycle, not otherwise specified, case rate.
    S4016Frozen in vitro fertilization cycle, case rate.
    S4017Incomplete cycle, treatment canceled prior to stimulation, case rate.
    S4018Frozen embryo transfer procedure canceled before transfer, case rate.
    S4020In vitro fertilization procedure canceled before aspiration, case rate.
    S4021In vitro fertilization procedure canceled after aspiration, case rate.
    S4022Assisted oocyte fertilization, case rate.
    1–10 of 16
    1/2
    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 yearsFewer than 4 frozen embryos available for transfer justifies additional IVF authorization
    FET exception noteIf member/enrollee continues with the diagnosis of infertility, FET with less than these embryo counts is considered medically necessary
    Sperm concentration threshold for ICSI consideration
    Motile sperm concentration thresholdFewer than 2 million motile spermatozoa per ejaculate
    ICSI general indicationICSI indicated for patients with previously failed fertilization or sperm parameters too low for conventional IVF
    Related documentationProviders should counsel patients on outcomes and potential risks of ICSI
    Age limits related to oocyte/egg donation or menopausal status
    Menopausal age consideration ≤54Policy references members with a female reproductive system who are ≤54 years of age and are menopausal (unless using a donor egg for premature diminished ovarian reserve or premature ovarian failure)
    Age >55Criteria section added regarding those with a female reproductive system who are >55 years of age (policy notes revisions)
    Donor egg/advanced age contextASRM Ethics Committee opinions cited for oocyte/embryo donation to women of advanced reproductive age (reference included in policy)

    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.

    • Document infertility duration: ≥12 months of cycles exposed to sperm (or ≥6 months if age ≥35) unless other criteria apply.
    • Document prior treatment attempts and failures (e.g., number of failed IUI cycles, failed conservative treatments for male factor infertility).
    • Provide ovarian reserve testing results (as applicable), prior IVF cycle details, and embryo availability when relevant.
    Billing Rule

    Coding, Medical Necessity, and Prior Authorization

    The CPT/HCPCS codes listed in this policy (see code list) require prior authorization when the service is a covered benefit. Include documentation in the PA request that ties the submitted codes to the medical necessity rationale. Coding inclusion does not guarantee coverage — payment is subject to member contract terms, exclusions, and limitations.

    • When submitting PA, reference the specific CPT/HCPCS codes and include clinical notes linking the code to policy criteria.
    • Providers should use current professional coding guidance; code lists in the policy are informational and not all-inclusive.
    Note

    Coverage Documentation and Contract Compliance

    Authorization decisions and payment are subject to the member's contract, plan exclusions, limitations, and applicable laws/regulations. This policy is a guide to medical necessity but does not guarantee payment. Providers must exercise professional judgment; the Health Plan's administrative policies, provider contract terms, and the member's evidence of coverage govern final coverage and payment determinations.

    • Coverage determinations may be overridden by state Medicaid rules when applicable.
    • Providers remain responsible for claims compliance and should retain documentation to support services billed.
    Step Therapy

    Prior Treatment Failure and Sequencing Notes

    Prior treatment failure or sequencing requirements in the clinical criteria must be documented when applicable. Examples: failure of conservative treatments for severe male factor infertility before IVF/ICSI, failure of at least three IUI cycles with oral agents for unexplained infertility prior to IVF, or using available frozen embryos prior to authorizing additional fresh IVF cycles when embryo-utilization thresholds in the policy are met.

    • Document number and dates of prior IUI cycles and outcomes when escalation to IVF is requested.
    • If frozen embryos exist, documentation must show embryo availability; frozen embryos are generally required to be used prior to authorizing additional IVF cycles when policy embryo thresholds are met.
    Documentation Required

    Provider Documentation and Claims Compliance

    Providers are expected to follow professional coding and billing practices and to maintain complete documentation supporting medical necessity for claims. The policy lists CPT and HCPCS codes that typically require PA; inclusion in the list is informational. Providers should reference up-to-date coding resources and ensure claims reflect authorized services, modifiers, and any plan-specific billing requirements to avoid denials.

    • Ensure claims correspond to the approved authorization (codes, dates of service, units).
    • Retain and produce clinical records upon request to substantiate billed services.

    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 contextMay be chosen by patients who for personal or religious reasons do not wish to create embryos in the laboratory, or after failed donor insemination; success rates similar to IVF
    PrerequisiteRequires at least one patent fallopian tube and justification that GIFT is preferable to standard IVF
    Zygote Intra-Fallopian Transfer (ZIFT) — definition and clinical context
    DefinitionZygote Intra-Fallopian Transfer (ZIFT): placement of fertilized eggs (zygotes) or embryos into the fallopian tube via laparoscopy
    Clinical contextAnalogous to GIFT; may benefit patients with difficult transcervical embryo transfer, uterine abnormalities, or recurrent failure with standard IVF
    PrerequisiteRequires laparoscopy and at least one patent fallopian tube; justification that ZIFT is preferable to standard IVF
    Intracytoplasmic Sperm Injection (ICSI) — definition and indications
    DefinitionIntracytoplasmic Sperm Injection (ICSI): laboratory microinjection of a single sperm into an oocyte to achieve fertilization
    Primary indicationsIndicated for severe male factor infertility (e.g., very low sperm concentration/motility, abnormal morphology) or prior/repeated fertilization failure with standard IVF
    Additional indicationsAlso indicated for use with cryopreserved oocytes, limited washed sperm, MESA/TESE-obtained sperm, and when PGT-M requires avoidance of extraneous sperm DNA
    ZIFT — alternate entry for ZIFT definition
    Alternate entry — ZIFTZIFT involves laparoscopic placement of fertilized eggs (zygotes) into the fallopian tube and is analogous to GIFT; may be used for difficult transcervical transfers or certain uterine abnormalities
    Clinical noteOverall success rates are similar to IVF but ZIFT requires laparoscopy and tube patency
    Policy codingPolicy includes HCPCS case rate codes for ZIFT when it is a covered benefit
    ICSI — alternate entry for ICSI definition
    Alternate entry — ICSIICSI is the microinjection of a sperm into an egg in the laboratory to achieve fertilization rather than allowing natural penetration
    When to considerConsider for prior failed fertilization, severely abnormal semen parameters, or when sperm are obtained by MESA/TESE
    CounselingPatients should be counseled on outcomes and small potential neonatal risks associated with ICSI
    Infertility definitions — ASRM committee opinion (2020) reference
    ASRM committee opinion (2020)References Practice Committee of the American Society for Reproductive Medicine: Definitions of infertility and recurrent pregnancy loss (Fertil Steril. 2020;113:533-5)
    Use in policyPolicy cites ASRM definitions as the source for clinical definitions of infertility and recurrent pregnancy loss
    Related referencesAdditional ASRM practice guidance and ethics opinions are cited elsewhere in the policy for oocyte/embryo donation and PGT use

    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.

    02/26annual_reviewLatest

    Annual review: multiple edits to IUI/IVF criteria including addition of ovulatory dysfunction items, reformatting of I.B.2 and removal of several notes and criteria; CPT and ICD-10 code table updates noted.