CurrentArizona Complete HealthPolicy CP.MP.130

Fertility Preservation

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).

Policy Summary

PayerArizona Complete Health

PolicyFertility Preservation

Policy CodePolicy CP.MP.130

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization and document medical necessity when requesting ovarian stimulation/retrieval, ovarian tissue retrieval, ovarian transposition, or sperm extraction for members at risk of treatment-related infertility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4main policy sections (I-IV)

15+CPT/HCPCS codes listed

ASCO/ASRM/NCCN/ACOGGuidelines cited

3Important Reminder sections

Coverage Criteria for Fertility Preservation

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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):

Female reproductive system - options: Any of the following are medically necessary prior to commencing medically necessary treatment likely to cause infertility (excluding voluntary sterilization): A) ovarian stimulation and retrieval of oocytes; B) ovarian tissue retrieval when (1) ovarian tissue shows no evidence of malignancy and (2) there is insufficient time for oocyte retrieval or the member is prepubertal; C) ovarian transposition (oophoropexy).

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.

Male reproductive system - options: Sperm extraction and retrieval procedures are medically necessary prior to commencing medically necessary treatment likely to cause infertility (excluding voluntary sterilization).

Insufficient evidence / not supported procedures

Not covered / insufficient evidence:

Female - insufficient evidence: Ovarian suppression with gonadotropin releasing hormone (GnRH) agonists or antagonists is considered insufficient evidence and is not supported for fertility preservation in members with a female reproductive system prior to commencing treatment likely to affect fertility.

Male - insufficient evidence: Testicular suppression with GnRH agonists or antagonists, and reimplantation or grafting of human testicular tissue, are considered insufficient evidence and are not supported for fertility preservation in members with a male reproductive system prior to commencing treatment likely to affect fertility.

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

CPT codes that support medical necessityCPTCovered

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.

1–10 of 15

1/2

HCPCS codes that support medical necessityHCPCSCovered

S4028

Microsurgical epididymal sperm aspiration (MESA).

CPT codes that do not support medical necessityCPTNot Covered

55899

Unlisted procedure, male genital system.

Provider Actions, Prior Authorization, and Documentation

Denial Risk

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.

Prior Authorization

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.

Documentation Required

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

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 therapy — definition and examples

DefinitionMedical treatments that can damage reproductive organs or gametes and lead to compromised or permanent infertility (examples include cytotoxic chemotherapy, radiation therapy, and bilateral oophorectomy).

Examples - chemotherapyCytotoxic chemotherapy agents used for cancer or some autoimmune/hematologic conditions may be gonadotoxic and impair fertility depending on agent, dose, and schedule.

Examples - radiationRadiation therapy affecting the pelvic or abdominal fields can damage ovaries or testes; risk varies with radiation field size and dose.

Examples - surgicalBilateral oophorectomy or other surgical resection/removal of reproductive organs (including for disease treatment or gender-affirming surgery) that results in loss of reproductive capacity.

Clinical noteFertility risk depends on multiple factors including patient age, treatment type and dose, and timing; counseling prior to gonadotoxic treatment is recommended.

Ovarian tissue cryopreservation — definition and brief effectiveness note

DefinitionSurgical retrieval and cryopreservation of ovarian cortical tissue for future reimplantation.

Effectiveness noteConsidered an established procedure with limited effectiveness in carefully selected patients; data on efficacy, safety, and reproductive outcomes remain limited.

Use casesOffered when there is insufficient time for ovarian stimulation and oocyte retrieval or for prepubertal patients who cannot undergo oocyte stimulation.

Fertility preservation — general definition

DefinitionClinical interventions intended to preserve reproductive potential prior to gonadotoxic therapy or gonadectomy, including oocyte or embryo cryopreservation, ovarian tissue preservation, and in vitro maturation as discussed in professional guidelines and committee opinions.

Included proceduresPlanned oocyte cryopreservation (oocyte retrieval after ovarian stimulation), embryo cryopreservation, ovarian tissue retrieval and preservation, and in vitro maturation where applicable.

Guidance sourcesProfessional guidance referenced includes ASRM committee opinions, NCCN AYA guidelines, and ACOG/other society statements informing indications and patient selection.

Timing and counselingFertility preservation counseling should be provided prior to initiating gonadotoxic therapy; options depend on available time and patient development (e.g., ovarian tissue cryopreservation for prepubertal patients).

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).