Prior authorization required for SET, reciprocal IVF, MET, and post‑4 cycles

Prior authorization is required for in vitro fertilization cycles with Single Embryo Transfer (SET) and for reciprocal IVF; authorization is for cycle tracking and does not require meeting a diagnosis of infertility for initial cycles. Prior authorization is also required for Multiple Embryo Transfer (MET) and for any IVF cycle after four prior IVF cycles that did not result in pregnancy and delivery (prior authorization is recommended for Commercial Products).

• SET and reciprocal IVF: prior authorization required for cycle tracking even when no infertility diagnosis is present (initial cycles).
• MET and any cycle after 4 IVF cycles: prior authorization recommended for Commercial Products; lack of prior authorization may lead to non-coverage.

Prior authorization recommended for SET/MET and post‑4 cycles (Commercial Products)

The policy recommends prior authorization for SET (for cycle tracking), MET cycles, and any cycle after four IVF cycles that did not result in pregnancy and delivery; AI (ICI or IUI) cycles do not require prior authorization when AI only is rendered.

• No prior authorization is needed when only AI (ICI or IUI) is rendered.
• Prior authorization is recommended for SET (cycle tracking), MET, and post‑4th IVF cycles for Commercial Products.

Storage and shipping: coverage limits and reimbursement

Storage and monitoring codes for cryopreserved cells are covered up to one year (12 months) per benefit year; cell shipping reimbursement is covered at 100% up to a $1,000 lifetime maximum per member. Claims for multiyear storage (over 12 months) are not covered.

• Covered storage codes: 89342, 89343, 89346, S4027, S4040 (covered up to 12 months per benefit year).
• Cell shipping reimbursement: 100% up to $1,000 lifetime maximum per member.
• Multiyear storage claims (over 12 months) are not covered; annual storage claims can be submitted once per benefit year.

Count each embryo transfer as one IVF cycle for authorization/adjudication

For cycle-counting and adjudication, each embryo transfer procedure (whether single or multiple, fresh or frozen) is counted as one IVF cycle; if pregnancy is not achieved, a new cycle begins with the next embryo transfer.

• Each embryo transfer (single or multiple; fresh or frozen) = 1 cycle for cycle limits.
• Cycle counting affects prior authorization and continuation review after four cycles.

Claims note: 58970 covered; use Z31.84 for elective fertility preservation

Code 58970 is listed as covered with no prior authorization required. For elective fertility preservation (limited to 3 cycles per lifetime), submit primary diagnosis Z31.84 to ensure correct claims processing and coordination of benefits.

• 58970 is covered and no prior authorization is required.
• When services are for elective fertility preservation, claims must be submitted with primary diagnosis Z31.84 (limited to 3 cycles lifetime).

IVF case‑rate/package codes listed (S4011, S4013–S4018; S4020/S4021 added)

The document enumerates case-rate (package) codes for complete, frozen, incomplete, and cancelled IVF-related cycles (S4011, S4013–S4018, with additional S4020/S4021 entries added effective 4/1/2025). The fragment lists these codes but does not state specific prior authorization requirements in these chunks.

• Case-rate codes include S4011, S4013–S4018; S4020 and S4021 appear in updated descriptors (effective 4/1/2025).
• These codes represent complete, frozen, incomplete, and cancelled IVF cycles.

Procedure and case‑rate code listings (S4011–S4018, 89281)

The policy lists specific procedure and case-rate codes associated with IVF and related procedures (S4011–S4018 and 89281 are referenced in this fragment); no explicit prior authorization language appears within these code-listing chunks.

• Referenced codes in the fragment include S4011–S4018 and CPT 89281 alongside assisted oocyte fertilization codes.
• The excerpt functions as a coding listing; prior authorization rules are not specified here.

Code enumeration present without explicit prior authorization language

This section lists case-rate and procedure S-codes (S4013–S4018, S4020, S4021) and CPT 58970; the chunks contain code enumeration but do not include explicit prior authorization requirement language.

• S4013–S4018 and S4020 are enumerated with Effective 4/1/2025 references.
• No explicit prior authorization wording is present in these code-list chunks.

IVF case‑rate codes enumerated; follow billing rules and related prior authorization policy

Multiple IVF-related case-rate codes (S4013–S4018, S4020, S4021) are enumerated and labeled with an effective date revision; the policy notes that correct case-rate selection and prior authorization are required per billing rules, and refers to related payer guidance for applicable prior authorization procedures.

• S4013–S4018, S4020, S4021 are listed as IVF and related case‑rate codes (text revised effective 4/1/2025).
• Providers should follow billing rules for correct case‑rate selection and consult the payer's Prior Authorization policy for applicable authorization requirements.

See payer's Prior Authorization policy for applicable requirements

Refer to the payer's 'Prior Authorization of Services, Treatments or Procedures' policy for applicable prior authorization requirements and processes that apply to services described here.

• This document references a separate Prior Authorization policy that governs authorization procedures.
• Providers should consult that related policy for specifics on how to request authorization.

Three AI cycles by a specialist establish infertility (AFAB without sperm exposure)

For AFAB members without exposure to sperm, infertility is established only after three consecutive AI cycles (ICI or IUI) performed by a qualified specialist; costs for medications, professional, technical and facility charges related to these three AI cycles are covered, but donor sperm procurement/processing/storage and home AI are not covered until infertility is established.

• Infertility is determined after 3 consecutive AI (ICI or IUI) cycles for AFAB members without sperm exposure.
• Costs associated with those three AI cycles are covered; donor sperm procurement/processing/storage not covered until diagnosis established; home AI (ICI/IUI) is not covered.

Documentation and review required to continue IVF after 4 failed cycles

Continuation of IVF services after four consecutive IVF cycles that did not result in pregnancy and delivery is considered medically necessary only when the requesting physician provides required documentation (number/type of past IVF/AI attempts, revised IVF methodology with literature-supported predicted success rate, and member informed consent); otherwise continuation is not medically necessary.

• Required physician submission for post‑4 cycles: documentation of number/type of past IVF/AI attempts; details of revised IVF methodology and predicted success rate supported by literature; documentation that the member accepts the predicted success rate.
• If these criteria are not met, continuation after 4 cycles is considered not medically necessary.

No step therapy directives specified

No step therapy directives are specified in this section of the policy.

• The policy explicitly states that no step therapy directives are specified in this section.

No step therapy or sequencing requirements specified

No step therapy requirements are described in these excerpts of the policy.

• The document contains coding and case-rate listings without step therapy or sequencing requirements.

No step therapy requirements in this excerpt

No step therapy directives or sequencing requirements are present in this excerpt.

• The policy text in these chunks focuses on code enumeration and does not impose step therapy.

Physician must document prior attempts, revised methodology, and member consent for post‑4 cycles

For requests after four IVF cycles that did not result in pregnancy and delivery, the requesting physician must submit: documentation of number and type of all past IVF/AI attempts; details of a revised IVF methodology with a predicted success rate supported by literature; and documentation that the member has been informed of and accepts the predicted success rate.

• Physician must include prior attempt history, revised methodology with literature support, and member consent/acknowledgement of predicted success rate.

Authorization required for SET and reciprocal IVF (cycle tracking)

Prior authorization is required for Single Embryo Transfer (SET) and reciprocal IVF for cycle tracking even when no medical criteria or infertility diagnosis is required for initial cycles.

• Authorization is for cycle tracking purposes only for initial SET and reciprocal IVF cycles.
• If cycles exceed four, additional medical criteria and documentation apply.

Required documentation for continuation after 4 IVF cycles

For requests to continue IVF after four cycles, the requesting physician must provide documentation of number/type of prior IVF/AI attempts, a revised IVF methodology with a literature‑supported predicted success rate, and documentation that the member was informed of and accepts the predicted success rate.

• These documentation items are used to determine approval of further transfer procedures after 4 failed cycles.

Member must submit reimbursement form if billed directly for shipping/storage

If the member was billed directly for cell shipping or storage, the member must submit the applicable Cell Shipping or Cell Storage Reimbursement Form to request reimbursement; forms are provided by the payer.

• Member-submitted claims require use of the provided Cell Shipping Reimbursement Form or Cell Storage Reimbursement Form (links in policy).

Document embryo transfer event to establish IVF cycle boundaries

Document the embryo transfer event (fresh or frozen) as the start/end of an IVF cycle for adjudication and for coordination with sperm retrievals or related procedures.

• Each embryo transfer marks the start/end of a cycle; documentation supports cycle counting and adjudication.

Use diagnosis Z31.84 for elective fertility preservation claims (3‑cycle lifetime limit)

For elective fertility preservation (limited to three cycles per lifetime), claims must be submitted with primary diagnosis Z31.84 to ensure correct claims processing and coordination of benefits; Z31.84 should not be used for members who meet the definition of infertility.

• Elective preservation is limited to 3 retrieval cycles per lifetime; use Z31.84 as the primary diagnosis for such claims.
• Do not use Z31.84 for members meeting the infertility definition (those have no lifetime cycle limits).

Procedure/case‑rate codes listed (coding fragment only)

The document lists procedure and case-rate codes (S4011–S4018 and related S-codes) and references CPT 89281 in association with IVF procedures; these chunks are code listings and do not specify prior authorization language.

• S4011–S4018 and 89281 appear in the coding fragments as descriptors for IVF-related services.
• These are coding listings without PA instructions in these chunks.

S-code enumeration and CPT reference (no PA language here)

This S-code enumeration and CPT references section lists S4013–S4020 and CPT 58970 in relation to IVF/GIFT/ZIFT cycles and cancelled procedures; no explicit prior authorization text is present in these chunks.

• S4013–S4020 are enumerated with descriptors for complete, frozen, incomplete, and cancelled cycles.
• CPT 58970 is referenced alongside these S-codes.

Document infertility status or elective fertility preservation intent on claims

Providers must document the member's infertility status or indicate elective fertility preservation intent, because coverage of certain codes differs depending on whether the member meets the definition of infertility or is undergoing elective preservation.

• Some codes are covered without an infertility diagnosis, while others are covered only when the member meets the infertility definition or is undergoing elective preservation—providers must document the member's status accordingly.

Verify benefits and eligibility with the payer before providing services

Providers should verify member-specific benefits and eligibility with the provider call center; benefits and eligibility are determined by the member's subscriber agreement or employer agreement, which supersede this medical policy.

• Contact the provider call center for member-specific benefit/eligibility questions before proceeding with services.

Failure to submit required post‑4 cycles documentation risks denial

After four IVF cycles that do not result in pregnancy and delivery, further transfer procedures require physician submission of documentation for review (number/type of prior attempts; revised methodology with literature‑supported predicted success rate; and member informed acceptance); failure to provide required documentation may lead to denial of additional transfers.

• Lack of the required post‑4 cycles documentation may result in denial of requests for further transfer procedures.

Not obtaining recommended prior authorization for MET or post‑4 cycles may cause denial

Lack of prior authorization (or failure to follow recommended prior authorization practices) for MET cycles or for cycles after four IVF cycles that did not result in pregnancy and delivery may result in non-coverage or claim denial; prior authorization is recommended for Commercial Products in these cases.

• Providers are advised to obtain prior authorization for MET and post‑4th IVF cycles to reduce risk of claim denial.

Previous sterilization may trigger administrative exclusion and denial

Requests for fertility services for a member who has undergone a previous sterilization procedure will undergo clinician review; if inability to conceive may be related to prior sterilization, an administrative denial may result (this is not a medical necessity review).

• Providers should be prepared for administrative review and possible denial when prior sterilization may explain infertility.

Donor eggs/sperm provided without infertility diagnosis risk noncoverage

Donor eggs and donor sperm are not covered when provided for members who do not meet the Definition of Infertility (donor sperm is also not covered for AMAB members with prior sterilization); use of donor material without meeting infertility criteria can trigger noncoverage.

• Donor eggs not covered for AFAB members who do not meet the infertility definition.
• Donor sperm not covered for AFAB or AMAB members who do not meet infertility definition, or for AMAB members with prior sterilization.

Incorrect cycle counting can affect benefit adjudication

Each embryo transfer is counted as one cycle for benefit adjudication; not adhering to the policy's cycle counting rules may affect benefit determination and prior authorization outcomes.

• Document transfers accurately because cycle counting impacts eligibility for continued services after four cycles.

Surrogate-related services excluded when surrogate is not plan member

Claims for services related to surrogate parents are excluded from coverage when the surrogate is not a member of this plan; providers should not expect coverage for surrogate-related services in those cases.

• All services related to surrogates are excluded when the surrogate is not a member of the plan.

Coding listing only — no explicit authorization/denial triggers in this fragment

This excerpt is principally a listing of procedure and case‑rate codes and does not contain explicit authorization or denial trigger language; providers should refer to other policy sections for actionable prior authorization rules.

• Code-listing fragments do not substitute for authorization guidance—consult the Prior Authorization policy or the coverage criteria sections.

Case‑rate code listing without PA/denial language

This coding fragment enumerates case‑rate/IVF codes but contains no explicit prior authorization or denial triggers; providers must consult coverage criteria and the Prior Authorization policy for authorization requirements.

• Code listings alone do not define authorization requirements.

No explicit denial or PA rules in these code fragments

No denial triggers or prior authorization rules are stated in these chunks; they are code‑focused fragments and do not replace the policy sections that define authorization and denial conditions.

• Providers should use the main coverage criteria and Prior Authorization policy to determine actionable requirements.

Some codes are covered only when member meets infertility definition — document accordingly

Coverage of certain codes (for example, 89335, 89344, 89354, S4023, S4025, S4026, S4028) is limited to members who meet the policy definition of infertility; claims lacking documentation that the member meets the infertility definition risk denial.

• Ensure documentation demonstrates the member meets the policy's infertility definition when submitting claims for these codes.

Do not bill non‑covered codes (e.g., 55400, 88240, 88241)

Services may be denied if billed under codes explicitly listed as non‑covered (for example, 55400 Vasovasostomy/vasovasorrhaphy, 88240, 88241); verify code coverage before submitting claims.

• Do not submit claims for non‑covered codes (55400, 88240, 88241) expecting reimbursement.