Currentblue cross blue shield - michiganPolicy N/A

Assisted reproductive techniques / In vitro fertilization (IVF) — Medicare Plus Blue enhanced benefit

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Defines Medicare Plus Blue (Medicare Advantage PPO) enhanced benefit coverage, payment, and provider requirements for assisted reproductive techniques including IVF and related services for group members; specifies eligibility, age limits, lifetime maximum, payable providers and locations.

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Currentblue cross blue shield - michiganPolicy N/A

Assisted reproductive techniques / In vitro fertilization (IVF) — Medicare Plus Blue enhanced benefit

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Sign up for all blue cross blue shield - michigan policy alerts

Know when blue cross blue shield - michigan releases new policies or updates existing guidance.

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Policy Summary

Payerblue cross blue shield - michigan

PolicyAssisted reproductive techniques / In vitro fertilization (IVF) — Medicare Plus Blue enhanced benefit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain a coverage determination and verify benefits and member cost-share prior to providing assisted reproductive services when coverage is uncertain.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$20,000lifetime maximum

≤43female coverage age

single/doubleembryo transfer rules

~25codes listed

Coverage Criteria

Covered when criteria met

Covered when ALL of the following are met:

Eligible plan and provider: Member enrolled in the Medicare Plus Blue Medicare Advantage PPO enhanced benefit plan and services performed by an eligible provider (M.D., D.O., Nurse Practitioner, or Physician Assistant) at an approved payable location.

Payable location for IVF services: Center for Reproductive Medicine (CRM) Michigan Medicine - Ann Arbor; lifetime maximum $20,000 applies.

Diagnosis and procedure mapping: The requested CPT/HCPCS procedure is one of the codes listed for this benefit and is billed with an appropriate supporting diagnosis code as required by the Conditions for Payment table.

Specific mapping: codes 58974, 58976, 89251, 89253, 89255, 89268, 89290, 89291, 89352 require diagnosis Z31.83; codes 58970, 76948, 89250, 89254, 89258, 89261, 89272, 89280, 89281, 89342 require Z31.83 or Z31.84; codes 89257, 89259, 89264, 89337, 89343, 89346 require N46.8, N46.9, N97.8, N97.9, or Z31.84.

Age and embryo transfer rules: The member meets the age-based eligibility and embryo transfer rules for assisted reproduction.age-based

Covered for women up to age 43. For ages ≤35: single embryo transfer only; for ages 36–43: double embryo transfer allowed. Iatrogenic infertility covered up to age 43. Members with genetic conditions causing early infertility covered up to age 26.

Benefit limits and payment: Services are payable subject to the plan's enhanced benefit fee schedule and member cost share; payment is the lesser of the allowed amount or charge less member cost share.

Lifetime maximum of $20,000 for IVF treatment; no frequency limits specified aside from the lifetime maximum.

Original Medicare noncoverage: Original Medicare does not cover in vitro fertilization. When Medicare does not cover a service, Medicare Advantage enhanced benefits may define coverage differently; providers should refer to the plan-specific enhanced benefit policy and member Evidence of Coverage for final determination. If a service is noncovered under the member's plan, a member may elect to receive the noncovered service, but the provider must obtain a coverage determination prior to delivering noncovered services and may not collect more than the appropriate member cost share without following plan rules.

This Enhanced Benefit Policy is intended to guide coverage decisions and does not replace the treating clinician’s independent medical judgment. It is not an authorization, certification, explanation of benefits, or a contract, and it does not guarantee payment for services. Providers remain responsible for determining appropriate care and for following plan-specific billing and documentation requirements when submitting claims.

Coding and Eligibility Details

Covered CPT Codes (part 1)CPTCovered

58970	Follicle puncture for oocyte retrieval (any method)
58974	Embryo transfer, intrauterine
58976	Gamete, zygote, or embryo intrafallopian transfer (any method)
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
89250	Culture of oocyte(s)/embryo(s), less than 4 days
89253	Assisted embryo hatching, microtechniques (any method)
89254	Oocyte identification from follicular fluid
89255	Preparation of embryo for transfer (any method)
89257	Sperm identification from aspiration (other than seminal fluid)
89258	Cryopreservation; embryo(s)

1–10 of 14

1/2

Covered CPT Codes (part 2)CPTCovered

89272	Extended culture of oocyte(s)/embryo(s), 4-7 days
89280	Assisted oocyte fertilization, microtechnique; ≤ 10 oocytes
89281	Assisted oocyte fertilization, microtechnique; > 10 oocytes
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique; ≤ 5 embryos
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique; > 5 embryos
89337	Cryopreservation, mature oocyte(s)
89342	Storage (per year); embryo(s)
89343	Storage (per year); sperm/semen
89346	Storage (per year); oocyte(s)
89352	Thawing of cryopreserved; embryo(s)

Applicable ICD-10 CodesICD-10

Z31.83	Encounter for assisted reproductive fertility procedure cycle
Z31.84	Encounter for fertility preservation procedure
N46.8	Other male infertility
N46.9	Male infertility, unspecified
N97.8	Female infertility of other origin
N97.9	Female infertility, unspecified

Age cutoff for female coverage

Female age cutoff for coverageUp to and including 43 years

Embryo transfer rules by ageAges ≤35: single embryo transfer; Ages 36–43: double embryo transfer

Iatrogenic infertilityCovered up to age 43

Genetic conditions causing early infertilityCovered up to age 26

Provider Actions & Billing Requirements

Prior Authorization

Verify benefits and obtain coverage determination before service

Obtain a coverage determination and verify member benefits and cost-share before providing services when coverage is uncertain; use the provider portal (Availity) or call the eligibility line. Coverage determinations should be obtained prior to providing items/services when coverage is uncertain and providers may verify benefits and cost-share via the provider portal or by phone.

Verify member eligibility and the Medicare Plus Blue PPO Enhanced Benefit Fee Schedule on Availity Essentials™ (Secure Provider Resources > Fee Schedules).
Call 1-866-309-1719 to confirm benefits and member cost-share if needed.

Note

Provider responsibilities and billing conduct (summary)

Follow all provider responsibilities before and during billing: confirm payable provider and location, collect only applicable cost share, file claims using required forms, and report codes with required specificity. Providers must bill according to Medicare Plus Blue rules, collect only the appropriate cost sharing, and follow payable provider/location requirements.

Definitions

Infertility — definition

DefinitionFailure to achieve pregnancy after 12 months or more of regular, unprotected intercourse or impairment of an individual's capacity to reproduce.

CausesFemale factors (e.g., pelvic adhesions, ovarian dysfunction, endometriosis), male factors, combined factors, or unknown causes.

Clinical noteA disease involving the reproductive system can prevent conception and result in infertility.

Assisted reproductive technology (ART) / Assisted reproductive techniques — definition

DefinitionFertility treatments in which eggs or embryos are handled, including in vitro fertilization and related procedures where gametes are manipulated in vitro.

Typical procedureIVF: oocytes harvested, inseminated in vitro, cultured, then transferred to the uterus or fallopian tubes.

Background

Infertility may arise from female factors (for example, pelvic adhesions, ovarian dysfunction, or endometriosis), male factors (such as abnormal semen parameters), combined factors, or be unexplained. It is commonly defined as the failure to achieve pregnancy after 12 months of regular, unprotected intercourse or as an impairment of an individual’s capacity to reproduce. Assisted reproductive technology (ART) encompasses interventions in which oocytes or embryos are handled outside the body—most commonly in vitro fertilization (IVF), where eggs are fertilized in vitro and resulting embryos are transferred to the uterus.

Policy Summary

Payerblue cross blue shield - michigan

PolicyAssisted reproductive techniques / In vitro fertilization (IVF) — Medicare Plus Blue enhanced benefit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain a coverage determination and verify benefits and member cost-share prior to providing assisted reproductive services when coverage is uncertain.

SourceLink

On This Page

Ensure services are provided by eligible provider types (M.D., D.O., Nurse Practitioner, Physician Assistant) and at approved payable locations (CRM Michigan Medicine - Ann Arbor for IVF).
Collect only the appropriate Medicare Plus Blue cost share from the member at time of service when possible; do not collect amounts beyond the allowed cost share.
Use the Medicare Plus Blue Enhanced Benefit Fee Schedule and accept payment as payment in full (providers may not balance-bill members for difference between allowed amount and charge).

Documentation Required

Documentation and coding requirements for billed claims

Submit required documentation and code claims to the highest specificity; include NPI and use specified claim forms. Providers may be required to submit documentation supporting billed claims and must report CPT/HCPCS and diagnosis codes to the highest level of specificity and include their NPI on all claims.

Bill on CMS 1500, UB-04, or 837 equivalent claim forms and follow Medicare Advantage PPO unique billing requirements.
Report CPT/HCPCS and diagnosis codes to the highest level of specificity and include National Provider Identifier on all claims.
Providers not contracted with BCBSM/BCN may be required to submit supporting medical records upon request.

Denial Risk

Hold‑harmless requirement when noncovered items are provided without prior determination

If a provider furnishes a noncovered item without first obtaining a coverage determination, the member must be held harmless for charges except applicable cost share. Seek a coverage determination before providing noncovered services when coverage is uncertain.

Do not have members sign an Advance Beneficiary Notice of Noncoverage to accept financial responsibility for noncovered items.
If coverage is uncertain, obtain a coverage determination from Medicare Plus Blue before providing the item to avoid hold‑harmless liability.

ExamplesIncludes gamete intrafallopian transfer, zygote intrafallopian transfer, cryopreservation of oocytes/embryos, oocyte/embryo donation, gestational surrogacy, and related techniques.