Fertility Preservation
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Defines medical necessity and non-coverage determinations for fertility preservation procedures (e.g., ovarian stimulation/retrieval, ovarian tissue retrieval/transposition, sperm extraction) for members whose medically necessary treatment is likely to cause infertility. Applies to members of health plans affiliated with Centene Corporation (Arizona Complete Health payer).
No material clinical or coverage changes in this revision.
Coverage Criteria for Fertility Preservation
Medically necessary fertility preservation procedures
Covered when ALL of the following are met for members whose medically necessary treatment is likely to cause infertility (excluding voluntary sterilization):
For members with female reproductive systems >= age 40 requesting retrieval of their own oocytes, documentation must note that the treating provider has evaluated age, infertility risk factors, measures of ovarian reserve, and considers use of the member's own oocytes a viable strategy for attempting future conception.
Insufficient evidence / not supported procedures
Not covered / insufficient evidence:
This policy applies to fertility preservation procedures provided prior to commencing medically necessary treatment that is likely to cause infertility and specifically excludes procedures requested as voluntary sterilization. For members with a female reproductive system, covered options prior to treatment likely to cause infertility include ovarian stimulation and oocyte retrieval, ovarian tissue retrieval when the tissue shows no evidence of malignancy and there is insufficient time for oocyte retrieval or the member is prepubertal, and ovarian transposition (oophoropexy). Documentation requirements apply for members with female reproductive systems aged ≥ 40 as described elsewhere in the policy.
When state Medicaid program coverage provisions conflict with this clinical policy, the state Medicaid provisions take precedence. Coverage decisions remain subject to all terms, conditions, exclusions and limitations of the member’s contract and to applicable state and federal requirements; providers should consult the relevant state Medicaid manual for specific coverage details.
Use of ovarian suppression with gonadotropin-releasing hormone (GnRH) agonists or antagonists is designated as having insufficient evidence to support fertility preservation in members with a female reproductive system prior to treatment likely to affect fertility. Similarly, testicular suppression with GnRH agonists/antagonists and reimplantation or grafting of human testicular tissue are designated as having insufficient evidence for fertility preservation in members with a male reproductive system.
Relevant Codes and Coding Guidance
| 00840 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified. |
| 00922 | Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles. |
| 55870 | Electroejaculation. |
| 55899 | Unlisted procedure, male genital system. |
| 58825 | Transposition, ovary(s). |
| 58970 | Follicle puncture for oocyte retrieval, any method. |
| 76856 | Ultrasound, pelvic (nonobstetric), real time with image documentation; complete. |
| 76948 | Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation. |
| 89254 | Oocyte identification from follicular fluid. |
| 89398 | Unlisted reproductive medicine laboratory procedure. |
| S4028 | Microsurgical epididymal sperm aspiration (MESA). |
| 55899 | Unlisted procedure, male genital system. |
Provider Actions, Prior Authorization, and Documentation
Denial risk for insufficient evidence items
When submitting requests for fertility preservation services, providers should be aware that procedures not meeting the medical necessity criteria in this policy may be denied. Items for which there is insufficient evidence in the published peer‑reviewed literature (for example, ovarian suppression with GnRH agonists/antagonists or testicular suppression with GnRH agents, and reimplantation/grafting of testicular tissue) are at particular risk for denial if requested.
- Procedures lacking supportive peer-reviewed evidence may be denied.
- Requests should include documentation demonstrating how criteria for medical necessity are met.
Coverage dependent on contract and legal requirements
Coverage of fertility preservation procedures is determined by the member's benefit contract and applicable law. This policy is a guide to medical necessity and does not guarantee coverage or payment. Providers and members must consult the member's evidence of coverage, certificate/policy, and any applicable state or federal requirements to determine actual benefit availability.
- Coverage subject to all terms, conditions, exclusions and limitations of the coverage document.
- State Medicaid provisions and Medicare NCDs/LCDs take precedence where applicable.
Provider responsibility and coverage guidance
This clinical policy is a guide to medical necessity and not a substitute for clinical judgment. Providers are expected to exercise professional medical judgment in determining appropriate care and are responsible for the medical advice and treatment of members. Include sufficient clinical documentation to support that proposed fertility preservation interventions are medically necessary for the member based on their clinical condition and treatment plan.
- Providers must document evaluation of risks and alternatives when applicable (for example, for members ≥ age 40 requesting oocyte retrieval, documentation that age, infertility risk factors, and measures of ovarian reserve were evaluated).
- Prior authorization requirements may vary by plan — follow the applicable plan's administrative requirements.
Prior authorization and administrative guidance
Prior authorization requirements and specific plan administrative processes may differ. Treat this policy as a medical‑necessity guide; always verify prior authorization rules and required documentation with the member's specific plan before initiating fertility preservation procedures.
- Confirm whether the requested service requires prior authorization for the member's plan.
- Attach relevant clinical records, treatment plan, and any required ovarian reserve testing or specialist evaluations when applicable.
Definitions and Background
Gonadotoxic treatments such as cytotoxic chemotherapy, radiation therapy, and surgical removal of reproductive organs can cause transient or permanent infertility; the likelihood of infertility varies by treatment type, dose, patient age, and underlying disease. Fertility preservation counseling should be offered before initiating gonadotoxic therapy, and available options depend on time before treatment and patient development (for example, ovarian tissue preservation may be considered when there is insufficient time for oocyte retrieval or for prepubertal patients).
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