Obtain prior authorization for SET, MET, and post‑4 IVF cycles

Prior authorization is required for Single Embryo Transfer (SET) IVF cycles for cycle tracking, for Multiple Embryo Transfer (MET) IVF cycles, and for transfers after 4 IVF cycles that did not result in pregnancy and delivery. Authorization is required even when no infertility diagnosis is present for cycle-tracking purposes; if cycle count exceeds four the post-4 documentation requirements (see documentation callout) must be submitted for review.

• SET authorization is for cycle tracking only; no medical criteria needed for SET authorization.
• MET cycles require prior authorization.
• Transfers after 4 unsuccessful IVF cycles require prior authorization and clinical documentation for continued treatment.

No preauthorization required for oocyte retrieval (CPT 58970)

Code 58970 (follicle puncture for oocyte retrieval) is covered and does not require prior authorization; other ART codes may still require authorization or meet medical necessity criteria as specified elsewhere in the policy.

• Submit 58970 without requesting prior authorization.
• Confirm other procedure codes against the policy lists — some are covered without preauthorization while others require meeting medical necessity criteria.

Follow code‑level preauthorization guidance for listed reproductive procedures

The procedural and case‑rate codes explicitly listed as “covered and no preauthorization required” may be billed without prior authorization; services not explicitly listed as no‑preauth remain subject to medical necessity review or prior authorization per the policy.

• Refer to the policy code lists (e.g., 58974, 58976, S4013–S4018, S4020–S4022, S4042) to identify which codes are covered and which require meeting medical necessity criteria.
• Do not assume codes not on the no‑preauth list are preauthorized — check policy requirements before scheduling.

Document required IUI attempts for AFAB members without sperm exposure before IVF

For AFAB members without exposure to sperm, infertility is determined after three artificial insemination (AI/IUI) cycles; to qualify for IVF, members under 40 must have two documented medicated IUI cycles, while members 40 and older require no medicated IUI cycles.

• Document three failed AI/IUI cycles using donor sperm for AFAB members without sperm exposure.
• Ensure medicated IUI cycle documentation: under 40 = 2 medicated IUI cycles required; 40+ = none required.

Provide documentation to support continuing IVF after 4 unsuccessful cycles

After four consecutive unsuccessful IVF cycles, the requesting physician must provide documentation of the number and type of prior IVF/IUI attempts, a revised IVF methodology with a literature‑supported predicted success rate, and documentation that the member has been informed of and accepts the predicted success rate.

• Detail number/type of all past IVF and IUI attempts (each embryo transfer counts as one cycle).
• Provide revised IVF methodology and literature‑supported predicted success rate.
• Include documentation the member understands and accepts the predicted success rate.

Use Z31.84 as primary diagnosis on elective fertility preservation claims

For elective fertility preservation claims, use primary diagnosis code Z31.84 (Encounter for fertility preservation procedure) on the claim to ensure correct processing and coordination of benefits.

• Elective fertility preservation is limited to 3 cycles per lifetime; include Z31.84 as the primary diagnosis on all related claims.

Document severe AMAB infertility with two qualifying semen analyses

Severe AMAB infertility must be documented on two separate semen analyses showing one of the policy‑specified thresholds: <10 million total motile sperm/ejaculate (pre‑wash), <3 million total motile sperm (post‑wash), or ≤2% normal forms (Strict Kruger morphology).

• Provide two semen analysis reports meeting at least one of the listed severe infertility criteria.
• Ensure laboratory reports include pre‑wash and post‑wash counts and Kruger morphology as applicable.

Elective fertility preservation — claim coding must use Z31.84

Elective fertility preservation claims must be submitted with primary diagnosis Z31.84; failure to use this diagnosis may result in incorrect processing or coordination of benefits.

• Z31.84 should not be used for members who meet the policy definition of infertility (those members have no lifetime cycle limits).
• For elective preservation (limited to 3 lifetime cycles), always submit Z31.84 as primary diagnosis.

Select correct diagnosis code and include medical necessity documentation

When services are for elective fertility preservation, use Z31.84 as the primary diagnosis; for infertility‑related services use the appropriate infertility diagnosis codes and include supporting medical necessity documentation when codes are covered only if medical necessity criteria are met.

• Elective preservation: primary diagnosis Z31.84 and adhere to the 3‑cycle lifetime limit.
• Infertility treatment: use infertility diagnosis codes; no lifetime cycle limits apply for members meeting infertility definition.

Clinician review required for members with prior sterilization

Requests for fertility services for a member with prior sterilization will undergo clinician review to determine whether the contractual exclusion applies; if inability to conceive may be related to the prior sterilization, the request may result in an administrative denial rather than a medical necessity review.

• Provide clear documentation addressing the relationship (or lack thereof) between prior sterilization and current infertility to support coverage consideration.
• Be aware that a determination that the exclusion applies is an administrative denial.

Risk of administrative denial when prior sterilization may explain infertility

Requests for fertility services for members with previous sterilization may be administratively denied if the inability to conceive is determined to be related to the prior sterilization; such cases are screened under the contractual exclusion.

• Anticipate possible administrative denial when prior sterilization could explain infertility.
• Include documentation that demonstrates medical certainty the sterilization is unrelated, if applicable.

Surrogacy services excluded when surrogate is not a plan member

All services related to surrogate parents are excluded when the surrogate is not a member of this plan; such claims will be denied.

• Do not submit claims for surrogate services unless the surrogate is a plan member.
• Confirm membership status of the surrogate before providing or billing any services.

Failure to use Z31.84 on elective preservation claims may cause denial or processing errors

Claims for elective fertility preservation must use primary diagnosis Z31.84; failure to submit elective preservation services with Z31.84 may lead to incorrect claims processing or denial.

• Elective preservation limited to 3 cycles per lifetime — ensure coding reflects elective status (Z31.84).
• Do not use Z31.84 for members meeting infertility definition.