Infertility treatment prior authorization (IUI/IVF) coverage criteria
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Form and policy governing prior authorization and coverage criteria for artificial intrauterine insemination (IUI) and in vitro fertilization (IVF) cycles for BCBSRI members; affects ordering providers requesting cycles and Utilization Management reviewers.
No material clinical or coverage changes in this revision.
Coverage / Medical Necessity Criteria
Medical necessity and coverage criteria
Covered when ALL of the following are met
Include time attempted before a miscarriage in the calculation.
These failed cycles must include the specified number of medicated IUI cycles to qualify for IVF services.
After four unsuccessful IUI/IVF cycles, the physician must submit a revised methodology and predicted success rate supported by literature and document that the patient was informed and accepts the proposed services.
Requests that exceed the plan's benefit limits are considered non-covered. Specifically, members are limited to 3 IUI/IVF attempts per 12-month period and a lifetime maximum of 8 IUI/IVF attempts that do not result in a successful pregnancy. Requests exceeding either the 12-month or lifetime limit may be denied as non-covered services.
After four unsuccessful IUI/IVF cycles, the physician must submit documentation describing a revised treatment methodology and provide the predicted success rate for the revised approach (supported by literature). The physician must also document that the patient has been informed of and accepts the proposed services.
For women without male partners or without exposure to sperm, infertility is defined as inability to conceive after six artificial insemination attempts (intracervical insemination or intrauterine insemination [IUI]) using donor sperm performed by a qualified specialist. The policy clarifies that these six donor sperm IUI cycles are not a covered benefit until the diagnosis of infertility is established after completion of the six cycles.
To qualify for IVF after those six donor IUI attempts, the failed cycles must include the age-based number of documented failed medicated IUI cycles: <35 years: 3 medicated IUI cycles; 36–39 years: 2 medicated IUI cycles; >40 years: none required.
Procedure Codes & Related Criteria
| CPT Code (blank on form) | Ordering provider to enter CPT code for requested IUI/IVF cycle as shown on form |
Prior Authorization & Documentation Requirements
Prior Authorization Required
Prior authorization is recommended for Commercial plans and required for BlueCHiP for Medicare for each IUI or IVF cycle. Fax the completed Infertility Treatment Form and supporting clinical documentation to BCBSRI Utilization Management at (401) 272-8885. Allow 14 days for Utilization Management to review the request.
- Applies to each IUI or IVF cycle
- Fax number: (401) 272-8885
- Commercial: prior authorization recommended
- BlueCHiP for Medicare: prior authorization required
- Allow 14 days for review by Utilization Management
Benefit Limits Exceeded — Non‑covered
Benefit limits: members have a yearly limit of three IUI/IVF attempts in a 12‑month period and a lifetime maximum of eight IUI/IVF attempts that do not result in a successful pregnancy and delivery. Requests that exceed these limits are non‑covered services.
- >3 IUI/IVF attempts in a 12‑month period = non‑covered
- >8 lifetime IUI/IVF attempts not resulting in pregnancy/delivery = non‑covered
Insufficient Documentation of Infertility — Risk of Denial
Insufficient documentation of infertility will risk denial. The member must have documented inability to conceive after one year of unprotected intercourse with sperm exposure (or six months if age ≥35). For women without sperm exposure (including donor sperm scenarios), infertility is defined as failure to conceive after six IUI attempts; those six donor‑sperm cycles are not a covered benefit until the diagnosis of infertility is established. For donor‑sperm patients seeking IVF, documentation must include the required number of failed medicated IUI cycles by age: <35 = 3, 36–39 = 2, ≥40 = 0. Include dates of unprotected intercourse or dates and outcomes of IUI cycles, CPT code(s), start date of the first cycle in the 12‑month benefit period, cycle number for this period, and total cycles to date.
- Document duration of unprotected intercourse with sperm exposure (1 year; 6 months if ≥35)
- For women without sperm exposure: document six IUI attempts using donor sperm (these six are not covered until infertility diagnosis established)
- After six donor‑sperm cycles, document failed medicated IUI cycles as required by age: <35 → 3; 36–39 → 2; ≥40 → 0
- Provide dates and outcomes for each cycle, CPT code(s), start date of first cycle in the 12‑month benefit period, cycle number for this period, and total number of cycles to date
- Include patient and ordering physician sections of the Infertility Treatment Form and any supporting clinical notes or test results
Key Definitions
Policy Background
Infertility services under this policy are available when the member meets the stated medical necessity criteria and is married, including a valid common-law marriage, and is an individual in whom fertility would naturally be expected. Infertility is generally defined as documented inability to conceive after one year of unprotected intercourse with exposure to sperm, or after six months for members aged 35 and older (time attempting to conceive before a miscarriage should be included in the calculation).
For women without sperm exposure, the policy uses failed artificial insemination attempts to establish the diagnosis: inability to conceive after six donor IUI attempts constitutes infertility for coverage consideration (see age-based medicated IUI requirements prior to IVF).
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