CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Expanded Fertility Services (Medical Coverage Policy)

Defines coverage, prior authorization, and medical criteria for expanded fertility services purchased by self-funded employer clients of Blue Cross & Blue Shield of Rhode Island; applies only to members with the expanded fertility benefit.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyExpanded Fertility Services (Medical Coverage Policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization for IVF (SET for tracking) and follow documentation requirements when continuing IVF after four unsuccessful cycles.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3egg/oocyte retrievals per lifetime

$1,000cell shipping lifetime max

12 monthsstorage coverage period

After 4IVF cycles before extra review

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Multiple Embryo Transfer (MET) medical necessity

MET is covered when ONE of the following is met

MET criteria: Members less than 35 years of age who have diminished ovarian reserve OR have had an unsuccessful single embryo transfer (SET).

MET criteria: Members who are 35 years old up to their 38th birthday after prior unsuccessful cycles.

MET criteria: Members (any age) who have undergone 2 unsuccessful SET IVF treatment cycles using their own fresh or frozen embryo.

MET criteria: Members who had an unsuccessful first treatment using their own fresh or frozen embryo OR had a successful IVF treatment followed by one failed SET in a prior cycle.

MET criteria: Members ages 38 years and older undergoing IVF treatment.

Continuation of IVF after 4 cycles

Continued IVF services after 4 consecutive IVF cycles that do not result in pregnancy and delivery are considered medically necessary when ALL of the following are met

After 4 cycles requirements: Documentation of number and type of all past IVF/IUI attempts is provided.

After 4 cycles requirements: Provide details of a revised IVF methodology and the predicted success rate supported by literature.

After 4 cycles requirements: Documentation that the member has been informed of the predicted success rate and accepts the proposed services.

Infertility definition and prerequisites for AFAB members

Infertility is defined and prerequisites for IVF include

Infertility duration: Inability to conceive after 1 year of unprotected intercourse with sperm exposure, or after 6 months if 35 years or older; for members without sperm exposure, inability to conceive after 3 artificial insemination attempts.

Include prior pregnancies/miscarriages in calculation of the attempted time where applicable.

IUI prerequisite: For AFAB members under 40, 2 medicated IUI cycles are required to qualify for IVF; members 40 and older require no medicated IUI cycles.

Medicated IUI costs (medication, professional, technical, facility) are covered as described; donor sperm procurement/processing/storage costs are not covered until infertility diagnosis is established.

Covered services (selected)

The policy lists covered procedures and preservation options

Covered procedures: Testing to determine infertility, MESA, TESE, TESA, ICSI and related services; cryopreservation for infertility diagnoses; cryopreservation for iatrogenic infertility; elective fertility preservation (subject to limits).

Hyaluronan Binding Assay is listed as not medically necessary for commercial products.

Donor gametes: Donor eggs and donor sperm are covered when used to treat infertility; procurement and related services are covered but agency facilitation fees and donor transportation costs are not covered.

For donor sperm, coverage applies for AFAB members as part of infertility treatment and for AMAB members for confirmed infertility not resulting from prior sterilization. Cryopreservation includes retrieval, freezing, storage, monitoring, shipping and thawing.

Covered services and clinical indications

Covered when criteria below are met or as noted for self-funded clients with expanded coverage:

Donor sperm coverage: Donor sperm is covered for treatment of infertility for AFAB members and for AMAB members for treatment of confirmed infertility (not resulting from prior sterilization). Procurement services are covered, but fees for finding a donor are not covered.

Cryopreservation of donor sperm includes retrieval, freezing, storage, monitoring, shipping and thawing.

Cell storage and shipping limits: Cell shipping reimbursed at 100% up to a $1,000 lifetime maximum; storage covered up to one year (12 months) per benefit year; multiyear storage claims are not covered.$1,000 lifetime; 12 months per benefit year

Annual storage claims can be submitted once per benefit year; monthly billing options exist; coverage details may vary by group/contract.

ICSI and sperm retrieval procedures: ICSI may be considered medically necessary for AMAB members with infertility due to low sperm count or impaired motility; MESA, TESA, TESE (including microTESE) are covered retrieval options depending on obstruction or azoospermia and are coordinated with IVF/ICSI.as clinically indicated

Severe AMAB infertility must be documented on semen analyses as specified in the policy.

Covered services (code-based)

Codes covered under this policy when medical necessity criteria are met or for specified indications

Covered Services: Multiple procedure and laboratory CPT/HCPCS/S codes related to IVF/ICSI, gamete/embryo services, sperm retrieval, cryopreservation, storage and related monitoring are covered either when medical necessity criteria are met or as specified per-code (some codes covered without a diagnosis of infertility or for elective fertility preservation).

See code lists in the policy for per-code distinctions; 58970 is noted elsewhere as covered without preauthorization for oocyte retrieval; S4042 is covered per cycle for ovulation induction management.

Services provided by egg donation facilitation agencies are not covered. Agency facilitation fees and donor transportation costs are specifically excluded because these charges are considered separate from the medical services related to egg retrieval, freezing, storage, monitoring, shipping and thawing, which are covered when applicable.

Claims for multiyear storage or storage beyond 12 months are not covered. Storage benefits are limited to one year (12 months) per benefit year; annual storage claims can be submitted once per benefit year and month-to-month billing is permitted, but coverage does not extend across multiple years without separate applicable benefit coverage.

Services to treat fertility are excluded for members who have previously undergone a sterilization procedure. An exception may be made only when there is medical certainty that the prior sterilization is in no manner related to the current inability to conceive; such requests will undergo clinician review, and administrative denial may result if the contractual exclusion applies.

Services to treat fertility are excluded for members who have undergone normal menopause. For the purposes of this policy, amenorrhea with an elevated FSH after age 42 is considered equivalent to normal menopause; menopause before age 42 is not considered normal menopause under this policy.

All services related to gestational or traditional surrogate arrangements are excluded from coverage when the surrogate is not a member. Coverage does not extend to services billed for or provided to non-member surrogates.

Certain procedures are explicitly non-covered, including vasovasostomy (CPT 55400) (unless performed for indications other than reversal of sterilization, in which case clinical review may occur). The policy also notes that there are no specific CPT codes for some laboratory assays (e.g., Hyaluronan Binding Assay, TESE, TESA), and directs use of an unlisted reproductive medicine laboratory procedure (89398) where appropriate.

The Hyaluronan Binding Assay (HBA) for sperm evaluation is considered not medically necessary for Commercial Products. The policy states that current evidence is insufficient to demonstrate that HBA improves net health outcomes and therefore it is not covered for these products.

Assisted hatching (mechanical disruption of the zona pellucida) has not been shown in randomized controlled trials and meta-analyses to significantly improve the live birth rate. Although some meta-analyses report improved clinical pregnancy rates, the overall evidence does not support routine use to improve live birth outcomes and it is not supported as standard medically necessary care.

Embryo co-culture techniques lack standardized methods and controlled trials demonstrating improved implantation or pregnancy rates. Multiple co-culture approaches have been studied, but no consistent benefit has been established in humans; therefore co-culture is not supported as medically necessary under this policy.

Services determined to be not medically necessary or otherwise non-covered are not reimbursable. Providers may not charge members for services found to be not medically necessary unless the provider has informed the member and obtained a prior written agreement in advance to continue treatment at the member's expense, per the provider participation agreement.

Coding and Limits

Storage and elective preservation codesCPT | ICD-10 | HCPCSCovered

89343	Storage (per year); sperm, semen
89342	Storage (per year); embryo(s)
89346	Storage (per year); oocyte
S4040	Monitoring and storage of cryopreserved per 30 embryos
S4027	Storage of previously frozen embryos
Z31.84	Encounter for fertility preservation procedure (primary diagnosis for elective fertility preservation)

Covered storage and monitoring codesCPT|HCPCS|mixedCovered

89343	Storage (per year); sperm, semen
89342	Storage (per year); embryo(s)
89346	Storage (per year); oocyte
S4040	Monitoring and storage of cryopreserved per 30 embryos
S4027	Storage of previously frozen embryos

Covered without preauthorization (note re: elective fertility preservation)CPTCovered

58970

Follicle puncture for oocyte retrieval, any method

Covered when medical necessity criteria metmixedCovered

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
89251	Culture of oocyte(s)/embryo(s), less than 4 with co-culture
89253	Assisted embryo hatching, microtechniques (any method)
89254	Oocyte identification from follicular fluid
89280	Assisted oocyte fertilization, microtechnique; <=10 oocytes
89281	Assisted oocyte fertilization, microtechnique; >10 oocytes
S4011	In vitro fertilization; including identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and visualization for development

1–10 of 19

1/2

Covered when medical necessity criteria metHCPCSCovered

S4042

Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management), per cycle

Covered without diagnosis of infertility / covered with infertility or fertility preservation conditionsmixedCovered

58321	Artificial insemination; intra-cervical
58322	Artificial insemination; intra-uterine
58323	Sperm washing for artificial insemination
89260	Sperm isolation; simple prep for insemination or diagnosis with semen analysis
89261	Sperm isolation; complex prep (Percoll/albumin gradient) for insemination or diagnosis with semen analysis
S4035	Stimulated intrauterine insemination (IUI), case rate
55870	Electroejaculation
89264	Sperm identification from testis tissue, fresh or cryopreserved
89335	Cryopreservation, reproductive tissue, testicular
89344	Storage (per year); reproductive tissue, testicular/ovarian

1–10 of 45

1/5

Non-covered / notes and unlisted codesCPTNot Covered

55400	Vasovasostomy, vasovasorrhaphy
88240	Cryopreservation, freezing and storage of cells, fees associated with storage are covered each cell line
88241	(Note in doc: no specific CPT codes for hyaluronan binding assay, TESE, TESA)
89398	Unlisted reproductive medicine laboratory procedure

inv-24: Egg retrieval limit for elective preservation — <= 3 per lifetime

Egg retrievals allowed for elective fertility preservationLimited to 3 egg/oocyte retrievals per member lifetime (cryopreservation for elective fertility preservation includes retrieval, freezing, storage, shipping and thawing)

Scope of limitApplies to elective fertility preservation only; not applicable to fertility treatments for infertility diagnosis

Claim coding noteWhen performed for elective fertility preservation, claims must use primary diagnosis Z31.84

inv-25: Cell shipping reimbursement — <= $1,000 lifetime maximum

Cell shipping reimbursement maximumReimbursed at 100% up to a $1,000 lifetime maximum per member

Covered itemsIncludes shipping of donor cells and member's own eggs, oocytes, sperm, and embryos for fertility or elective purposes

Interaction with storage limitsShipping benefit is separate from storage; both subject to applicable group/contract benefits

inv-26: Storage coverage period — 12 months per benefit year

Storage coverage period per benefit yearStorage covered up to one year (12 months) per benefit year; annual storage claims may be submitted once per benefit year

Monthly billing optionMonthly or month-to-month storage billing is also accepted

Multi-year storageClaims for multi-year storage or storage over 12 months are not covered

inv-27: AMAB severe infertility semen analysis thresholds — Post-wash total motile sperm ≤ 3 million; Pre-wash total motile sperm ≤ 10 million; Strict Kruger morphology ≤ 2% (documented on two semen analyses)

Post-wash total motile sperm thresholdPost-wash total motile sperm ≤ 3 million (documented on two semen analyses)

Pre-wash total motile sperm thresholdPre-wash total motile sperm (per ejaculate) ≤ 10 million (documented on two semen analyses)

Strict Kruger morphology thresholdStrict Kruger morphology ≤ 2% normal forms (documented on two semen analyses)

inv-28: Elective fertility preservation lifetime limit — 3 per lifetime

Elective fertility preservation cycle limitLimited to 3 fertility preservation cycles per member lifetime (includes cryopreservation of eggs/oocytes/embryos/sperm)

Claims processing requirementClaims for elective fertility preservation must be submitted with primary diagnosis Z31.84 to ensure correct processing

InclusionsCryopreservation coverage includes retrieval, freezing, storage, monitoring, shipping and thawing for elective preservation

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for in vitro fertilization (IVF) with single embryo transfer (SET) for tracking purposes. Lack of required prior authorization for MET (when specified) or after four IVF cycles may result in denial or require additional review.

SET (Single Embryo Transfer) IVF — prior authorization required for tracking
MET (Multiple Embryo Transfer) IVF — prior authorization recommended for Commercial products
No authorization needed when only IUI is rendered

Documentation Required

Documentation Required After 4 IVF Cycles

After 4 consecutive IVF cycles (SET or MET) that do not result in pregnancy and delivery, the requesting physician must provide documentation for review before additional transfer procedures will be authorized.

Documentation of the number and type of all prior IVF and IUI attempts
Details of revised IVF methodology with supporting literature and predicted success rate
Confirmation the member has been informed of and accepts the predicted success rate

Prior Authorization

IUI Prerequisite for IVF

For members assigned female at birth (AFAB), authorization for IVF may require prior failed medicated intrauterine insemination (IUI) cycles to establish infertility, except for members 40 years and older.

Members under 40 years: documentation of 2 failed medicated IUI cycles required to qualify for IVF authorization
Members 40 years and older: no medicated IUI cycles are required to qualify for IVF authorization
Duration-of-attempt rules (1 year unprotected intercourse, or 6 months if ≥35) still apply when applicable

Documentation Required

ICSI Clinical Indications and Documentation

Intracytoplasmic sperm injection (ICSI) is indicated when sperm parameters preclude unassisted fertilization; documentation of clinical indication is required to support medical necessity.

ICSI indicated for insufficient sperm numbers, abnormal morphology, or poor motility that preclude unassisted insemination
For AMAB members, severe infertility should be documented with two semen analyses meeting specified thresholds (e.g., ≤3 million total motile sperm post-wash or ≤10 million total motile sperm pre-wash, or ≤2% normal Kruger morphology)

Denial Risk

Denial Risk and Billing Notice

Services determined to be not medically necessary or excluded by contract (for example, prior sterilization or normal menopause) may be denied; providers may not charge members for denied non-covered services without prior written agreement.

Requests for members with previous sterilization will be reviewed; exclusion typically applies unless reversal or clear documentation proves otherwise
Services for members in normal menopause (amenorrhea and elevated FSH after age 42) are excluded
Providers must obtain written member agreement before billing for non-covered services

Background

Assisted reproductive technologies (ART) encompass fertility treatments in which eggs or embryos are handled, including procedures such as oocyte retrieval and embryo transfer, as well as cryopreservation, donor gametes, and gestational surrogacy. The policy distinguishes coverage and clinical pathways for members assigned female at birth and assigned male at birth, and addresses both infertility treatment and fertility preservation scenarios.

Definitions

inv-44: Assisted Reproductive Technologies (ARTs) — Fertility treatments in which eggs or embryos are handled, including oocyte retrieval, embryo transfer, gamete/zygote intrafallopian transfer

Definition of ARTsFertility treatments in which eggs or embryos are handled, including oocyte retrieval, embryo transfer, gamete/zygote intrafallopian transfer, cryopreservation, donation, and gestational surrogacy

Examples includedIncludes but is not limited to oocyte retrieval, embryo transfer, gamete intrafallopian transfer, zygote intrafallopian transfer

Contextual noteARTs encompass procedures where eggs or embryos are manipulated outside the body

inv-45: Elective fertility preservation — Storing eggs, oocytes, or sperm for future use without need to prove infertility or underlying medical condition; claims must use Z31.84 when applicable

Elective fertility preservation definedStoring eggs, oocytes, or sperm for future use without need to prove infertility or underlying medical condition

Claim coding requirementWhen performed for elective fertility preservation, claims must be submitted with primary diagnosis Z31.84

What is coveredCryopreservation includes retrieval, freezing, storage, monitoring, shipping and thawing when billed for elective preservation

inv-46: IUI (intrauterine insemination) — Procedure that bypasses the cervix to place sperm in the uterine cavity to target the ova

IUI procedure descriptionIntrauterine insemination bypasses the cervix to place sperm in the uterine cavity, often timed with ultrasound to track follicular development

AdjunctsFertility drugs may be used in conjunction with IUI to maximize chances of pregnancy

Comparison to ICIICI (intracervical insemination) is now rarely used compared to IUI

inv-47: Assisted hatching — Mechanical disruption of the zona pellucida to aid embryo 'hatching'; randomized trials have not shown a significant improvement in live birth rate

Assisted hatching definitionMechanical disruption of the zona pellucida to aid embryo 'hatching' during implantation

Evidence summaryRandomized controlled trials and meta-analyses have not found that assisted hatching significantly improves live birth rate, though some meta-analyses report improved clinical pregnancy rates

Clinical implicationRoutine use is not supported by RCT evidence for improved live birth

inv-48: Blastocyst transfer — Extended embryo culture (>4 days) to blastocyst stage; evidence supports higher live birth rates versus cleavage-stage transfer

Blastocyst transfer definitionExtended culture of oocytes/embryos for greater than 4 days to the blastocyst stage

EvidenceRCTs, observational studies and meta-analyses show higher live birth rates with blastocyst transfer compared to cleavage-stage transfer

Clinical effectMay allow fewer embryos transferred and reduce higher-order multiple pregnancies

inv-49: TESA — Testicular sperm aspiration (TESA): percutaneous needle aspiration of testicular tissue/sperm, performed with local anesthesia

TESA descriptionTesticular sperm aspiration (TESA) is percutaneous needle aspiration of testicular tissue/sperm, performed with local anesthesia and coordinated with egg retrieval

LimitationsTESA may occasionally fail to provide sufficient tissue/sperm, requiring open testis biopsy

SettingPerformed in OR or office with local anesthesia as coordinated with IVF/ICSI cycles

inv-50: TESE / MicroTESE — Testicular sperm extraction (TESE): surgical incision and examination of testicular tubules for sperm, usually with sedation in OR

TESE/MicroTESE descriptionTesticular sperm extraction (TESE) involves a small incision to examine tubules for sperm; MicroTESE is optimal for azoospermia due to production problems

Procedure settingUsually performed in the operating room with sedation, but can be done in office with local anesthesia

Typical practiceSperm are often cryopreserved during the procedure for future IVF/ICSI

inv-51: Hyaluronan Binding Assay — HBA: a semen laboratory assay to evaluate sperm maturity in fresh semen as part of standard semen analysis

Hyaluronan Binding Assay (HBA) definitionA semen laboratory assay that evaluates sperm maturity in a fresh semen sample to predict fertilization potential

Intended useProposed as a component of standard semen analysis in diagnosis of suspected infertility

Coverage noteNo specific CPT code exists for HBA in the document; 89398 may be used for unlisted reproductive medicine laboratory procedures