Blue Cross MA Assisted Reproductive Coverage Update

Coverage Criteria for Assisted Reproductive Services

IVF/ZIFT/GIFT Medical Necessity

Covered when ANY of the following conditions are present and the member meets the policy definition of infertility:

Indications: Tubal factor infertility; Pelvic adhesive disease; Endometriosis; Male factor infertility as defined in this policy; Member has met the criteria for infertility coverage as defined in this policy.

IVF Embryo Transfer Protocols (SET/STEET)

Coverage and required embryo transfer strategy vary by member age and cycle number:

Members <35: 1st IVF cycle: single embryo transfer (SET) is required. If there are no top-quality embryos after thawing, two or more embryos of any quality may be transferred. 2nd IVF cycle: STEET (single thawed elective embryo transfer) is required if member has one or more embryos frozen; if no frozen embryos, perform SET. 3rd and subsequent IVF cycles: SET/STEET not required.

All frozen embryos must be used before another cycle may be approved.

Members who had prior live birth from IVF and are <38: 1st IVF cycle: STEET required if the member has one or more embryos frozen; if no frozen embryos, perform SET. 2nd and subsequent cycles: SET/STEET not required.

Members 35-38: 1st IVF cycle: SET is required.

Members >=38: Members 38 years of age and older do not need to attempt SET or STEET.

Donor egg recipients: For donor egg IVF (donor <34 years): 1st IVF cycle: SET required; 2nd cycle: STEET required if frozen embryos exist; 3rd+ cycles: SET/STEET not required. All frozen embryos must be used before another cycle may be approved.

Frozen Embryo Transfer (FET) Coverage

FET is covered when ANY of the following are true:

FET coverage conditions: Embryos were created during a BCBSMA-approved IVF cycle; OR member meets infertility criteria (either at time of freezing or prior to transfer) and has their own frozen embryos available; OR member was approved for donor egg/embryo and will use donor egg/embryo for FET.

For frozen embryos created in cycles not initially approved by BCBSMA, uterine cavity evaluation within 24 months and treating provider diagnosis of infertility are required before approval.

Assisted Embryo Hatching

Assisted hatching is covered when ANY of the following are present:

Assisted hatching coverage: Documented prior pregnancy following IVF with assisted hatching; OR three or more implantation failures after embryo transfer cycles (failure to detect rise in hCG).

Assisted hatching is not covered when PGT-M/PGT-SR is performed per exclusions.

ICSI Coverage for Male Factor and Other Indications

ICSI is covered when ANY of the following criteria are met:

Baseline male factor criteria: At least 2 unprocessed semen analyses show <10 million total motile sperm; OR at least 2 processed semen analyses show ≤3 million total motile sperm; OR at least 2 analyses show ≤2% strict Kruger normal forms.

ICSI for donor sperm is not covered.

Additional ICSI indications: ICSI covered on the day of egg retrieval if same-day post-processing semen meets the above thresholds (retrospective authorization allowed); OR covered for reduced fertilization on a prior IVF cycle (<40% fertilization with standard insemination); OR covered to fertilize cryopreserved eggs; OR covered when performed for approved preimplantation genetic testing.

Donor Egg/Embryo Coverage

Donor egg/embryo cycles are covered for the following clinical circumstances:

Medical indications for donor egg/embryo: (1) Medical illness causing loss of egg quantity: premature inadequate harvest (≥2 IVF cycles with ≤6 eggs retrieved), absent ovaries prior to age 40, or premature ovarian insufficiency; (2) Specific genetic egg defects as an alternative to PGT when MP 088 criteria met or recurrent pregnancy loss with balanced translocation; (3) Individuals who require medical intervention to achieve pregnancy (e.g., biological male or same-sex male couple) — covered services include fertilization, embryology services, and cryopreservation/storage of embryos up to 24 months.

Donor must be <34 years of age. Assisted hatching, FET, and surrogate maternity services are not covered for donor egg cycles in specified circumstances.

Sperm Retrieval, Donor Sperm, and Cryopreservation

Coverage conditions for donor sperm, surgical retrieval, and cryopreservation:

Donor sperm coverage: Donor sperm is covered (up to 2 vials per cycle) for individuals who require medical intervention to achieve pregnancy (including same-sex couples); the enrolled female member must meet IVF evaluation criteria to be eligible when used with IVF. Donor sperm reimbursed at time of use for IUI or IVF.max 2 vials per cycle

MESA coverage: MESA is covered only for congenital absence or congenital obstruction of the vas deferens (typically diagnosed by absence of fructose in semen) and confirmed by exam; MESA is not covered when there is <5% chance of live birth.

Microdissection-TESE coverage: Microdissection-TESE is covered for non-obstructive azoospermia and spinal cord injury resulting in inability to ejaculate; TESE is not covered when there is <5% chance of live birth.

Covered services and conditions

Covered services and specific conditions under which they are allowed:

Sperm/testicular cryopreservation for active infertility treatment: Sperm storage/banking is covered for members who have undergone covered MESA or microdissection-TESE for up to 24 months.24 months

Cryopreservation for azoospermia: Cryopreservation of testicular tissue/sperm is covered for adult biological males with azoospermia in conjunction with testicular biopsy to identify sperm for ICSI if sperm are found.

Electroejaculation is covered.

Surrogate/gestational carrier exceptions: For BCBSMA members with a clear medical contraindication to pregnancy using their own eggs who self-pay a gestational carrier, BCBSMA will pay for the member's infertility evaluation, stimulation, retrieval, fertilization, freezing and storage; embryology services for embryo creation are covered for same-sex male or single male members.

Not covered / exclusions

Listed services and scenarios that are not covered:

Sperm storage limits and convenience requests: Sperm freezing and storage exceeding 24 months; sperm storage for convenience or 'back-up' of a fresh specimen; TESA.24 months

Specific non-covered tests/procedures: Numerous advanced laboratory tests and procedures and experimental techniques (e.g., hemizona test, serum anti-sperm antibody testing, sperm DNA fragmentation assays, advanced sperm selection techniques, co-culture of embryos, genetic engineering, elective egg freezing for fertility preservation, endometrial scratching, embryo glue, hCG uterine infusion, uterine artery vasodilation, and others) are not covered.

Partner and surrogate services not covered: Coverage for a partner's services when partner is not a member (except procurement/processing if not covered by partner), services related to achieving pregnancy through a surrogate/gestational carrier, and use of donor egg with a gestational carrier when the female member is not physically treated are not covered (with limited exceptions for member evaluation and embryology services when gestational carrier is self-paid).

Sterilization reversal and post-reversal infertility treatment criteria

Conditions under which infertility treatment after sterilization reversal is covered:

Sterilization reversal generally not covered: Sterilization reversal is not covered; infertility treatment needed as a result of prior voluntary sterilization or unsuccessful sterilization reversal is not covered unless specific criteria are met.

Coverage after reversal — biological females: Member must meet the definition of infertility by a diagnosis unrelated to the sterilization procedure/reversal AND have a hysterosalpingogram (HSG) showing at least one patent fallopian tube.

Coverage after reversal — biological males: Two post-reversal semen analyses (6 months apart) showing ≥20 million total motile sperm AND ≥3% normal forms, AND member has a normal semen analysis 6 months prior to the infertility service request.>=20 million motile; >=3% normal forms

Medically necessary assisted reproductive services

Covered when members meet the definition of infertility and required documented evaluation demonstrates medical necessity:

General coverage: Member meets definition of infertility (failure to conceive after 12 cycles with expected ovulation and presence of semen) and is not undergoing menopause or perimenopause; individuals and same-sex couples lacking reproductive capacity may qualify.

State mandate requires coverage for infertility diagnosis and treatment including AI, donor gametes/embryos, and IVF.

Services covered: Assisted reproductive services including artificial insemination, donor gametes or donor embryos, in vitro fertilization, embryology services, donor egg cycles, donor embryo cycles, reciprocal IVF and related medically necessary procedures per ASRM guidelines.

Medically necessary indications revised 1/1/2026 to explicitly include donor gametes and reciprocal IVF.

Evaluation requirement: Required documented clinical workup intended to identify members with greater than a 5% chance of live birth; evaluation requirements updated per literature review.>5% chance of live birth

The policy lists multiple procedures that are explicitly not covered. Examples include: sperm penetration assays used to decide on ICSI during an IVF cycle, mock transfers, and rescue ICSI performed when low fertilization is discovered during an IVF cycle. Also excluded are FET or use of thawed gametes when embryos/eggs/sperm were not initially approved by BCBSMA or when infertility criteria were not met at the time of freezing or transfer, FET for reciprocal IVF when not transferred to the partner, and FET/use of thawed gametes for gestational carriers in any circumstance.

An extensive set of specific tests, advanced laboratory techniques, and partner/surrogate services are non‑covered. Examples of non‑covered tests/procedures include gender selection, hemizona (human zona binding) test, serum anti‑sperm antibody testing, sperm DNA fragmentation assays, and a range of advanced sperm selection techniques (e.g., PICSI, Zeta potential, MACS). Other non‑covered items include co‑culture, embryo glue, endometrial scratching, IVIG/G‑CSF/intralipid infusions, elective egg freezing for fertility preservation, and genetic engineering procedures. Partner/surrogate related exclusions include no coverage for a partner’s services when the partner is not a member, and no coverage for services provided to a surrogate or gestational carrier (transfer and pregnancy‑related costs are not covered).

Policy history and current exclusions reflect coding and product clarifications. CPT 59866 (multifetal pregnancy reduction) has been removed from the policy and coverage is now determined by the subscriber certificate. The policy also specifies that certain commercial products such as Cryochoice kits are non‑covered. Additionally, FET and use of thawed gametes remain non‑covered in situations described elsewhere in the policy (for example, when not initially approved by BCBSMA or when infertility criteria were not met at time of freezing/transfer).

Services falling into the excluded categories are considered Not Medically Necessary when performed for convenience or outside stated clinical indications. Representative examples include sperm freezing or storage beyond 24 months, sperm storage requested as a convenience or 'back‑up' for a fresh specimen, TESA, ICSI when using donor sperm, and donor egg/embryo cycles performed solely for age‑related decline in egg quantity or quality. Fees related to donor procurement, donor legal services, and purchase/transport of donor gametes or embryos are also excluded and considered not covered.

The policy identifies additional advanced, experimental, or unsupported reproductive tests and techniques as non‑covered. These include artificial oocyte activation, in vitro maturation of eggs, sperm hyperactivation processing, sperm DNA fragmentation assays, and other advanced sperm selection or manipulation methods. Also listed are procedures like elective egg freezing for fertility preservation (unless otherwise covered), and investigational/experimental interventions such as genetic engineering or peritoneal ovum and sperm transfer — all of which are excluded.

Sterilization reversal and subsequent infertility treatment are generally not covered. Infertility care required as a result of prior voluntary sterilization or an unsuccessful sterilization reversal is excluded unless specific, policy‑defined criteria are met. For female members a required condition for coverage after reversal is meeting the policy definition of infertility unrelated to the sterilization and demonstration of at least one patent tube by HSG; for male members the policy requires documented post‑reversal semen parameters (two analyses, six months apart) with thresholds specified in the policy before coverage is considered.

Coding and Billing Information

CPT Codes - Coding Information for Professional Providers (selected)CPT

54900	Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral
54901	Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral
58321	Artificial insemination; intra-cervical
58322	Artificial insemination; intra-uterine
58323	Sperm washing for artificial insemination
58340	Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
76831	Saline infusion sonohysterography (SIS), including color flow Doppler, when performed
74740	Hysterosalpingography, radiological supervision and interpretation
S4026	Procurement of donor sperm from sperm bank
S4028	Microsurgical epididymal sperm aspiration (MESA)

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Coding Information for Reproductive Specialist ProvidersCPT

58970	Follicle puncture for egg retrieval, any method
S4011	In vitro fertilization, including identification and incubation of mature eggs, fertilization, incubation of embryo(s), visualization
S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016	Frozen in vitro fertilization cycle, case rate
S4018	Frozen embryo transfer procedure cancelled before transfer, case rate
S4022	Assisted oocyte fertilization, case rate
89250	Culture of egg(s)/embryo(s), less than 4 days
89253	Assisted embryo hatching, microtechniques (any method)
89254	Egg identification from follicular fluid

Coding Information for Contracted Sperm BanksCPT

S4030	Sperm procurement & cryopreservation services; initial visit
S4031	Sperm procurement & cryopreservation services; subsequent visits
89259	Annual sperm storage due to other medical treatment rendering a member infertile

Removed/clarified codes in historyCPT

59866

Multifetal pregnancy reduction (code removed from policy)

Coding clarifications notedmixed

unspecified

Prior authorization and coding clarifications recorded (specific covered CPT/ICD codes not present in this excerpt)

Male factor semen analysis thresholds

Unprocessed semen analysesAt least 2 unprocessed semen analyses showing <10 million total motile sperm

Processed semen analysesAt least 2 processed semen analyses showing ≤3 million total motile sperm

Strict Kruger normal formsAt least 2 analyses showing ≤2% strict Kruger normal forms

Cryopreservation storage duration

Maximum storage duration (embryos)Embryo freezing and storage covered for up to 24 months when embryos are created during an approved BCBSMA IVF cycle

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Embryo use and storage prior authorization

All frozen embryos and/or top-quality gametes (eggs or sperm) created during a BCBSMA‑approved IVF cycle must be used before authorization will be approved for another fresh IVF cycle.

Embryo freezing and storage covered up to 24 months when created during an approved BCBSMA IVF cycle.

Prior Authorization

Prior authorization requirements

Prior authorization is required for most infertility treatments related to assisted reproductive technology for outpatient services and is required for all inpatient services described in this policy. Check the member's certificate/plan for product‑specific authorization rules.

Inpatient: prior authorization required for all products.
Outpatient: authorization requirements vary by product; infertility treatment prior authorization generally required except for routine IUI (see exceptions).
Use Authorization Manager to submit initial requests (facility NPI and servicing surgeon NPI required). For out‑of‑network providers, fax requests to 800‑836‑1112.

Background

In vitro fertilization (IVF) and related assisted reproductive technologies are medically indicated for standard infertility diagnoses such as tubal factor, pelvic adhesive disease, endometriosis, and male factor infertility when members meet the policy definition of infertility (failure to conceive after 12 menstrual cycles with expected ovulation and presence of semen). The policy specifies embryo transfer strategies by age and cycle number (for example, SET required for first cycle in members <35) and includes coverage and requirements for donor gametes, cryopreservation (up to 24 months when created during an approved BCBSMA cycle), assisted hatching in limited circumstances, ICSI for defined male‑factor thresholds, and prior authorization and documentation requirements intended to identify members with a greater than 5% chance of live birth.

Definitions

Male factor infertility (policy-defined)

Definition (policy) — primary criteriaMale factor infertility is defined by semen analysis thresholds: at least 2 unprocessed analyses with <10 million total motile sperm; or at least 2 processed analyses with ≤3 million total motile sperm; or at least 2 analyses with ≤2% strict Kruger normal forms

Requirement for multiple specimensThresholds require the same type of abnormality present in each specimen (at least two analyses)

Implication for ICSI coverageICSI is covered when these male factor thresholds are met for non-donor sperm

Infertility

Standard definitionFailure to conceive a pregnancy after 12 menstrual cycles during which ovulation is expected and semen presumed to contain sperm has been present

Exclusions

OpenPayer

Medical Policy Assisted Reproductive Services

Coverage Criteria for Assisted Reproductive Services

Coding and Billing Information

Provider Requirements, Prior Authorization, and Denial Risks

Background

Definitions