CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Uterus Transplantation for Absolute Uterine Factor Infertility

This policy governs coverage of uterus transplantation as a treatment for absolute uterine factor infertility for Blue Cross Blue Shield - Rhode Island members. It states the payer's coverage stance and coding guidance affecting providers submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyUterus Transplantation for Absolute Uterine Factor Infertility

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date10/01/2022

Next Review DateN/A

Key ActionDo not submit claims for uterus transplantation or the listed donor/recipient procedure codes because they are identified as not covered / not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

33uterus-transplant–associated live births in U.S. as of 2024

64%–78%surgical success (deceased donor)

19% / 18%complication rates

80%preterm birth rate

1 in 500estimated AUFI prevalence

Coverage determination

Not Covered / Not Medically Necessary

Not medically necessary / Not covered

ALL of the following

Uterus transplantation for absolute uterine factor infertility is not covered — the evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Benefits may vary between groups and contracts. Refer to the Evidence of Coverage or Subscriber Agreement for applicable not medically necessary / not covered benefits and coverage determinations.
The following uterus transplantation–related procedure codes are considered not medically necessary / not covered as listed below (not covered for Medicare Advantage; not medically necessary for Commercial products).
See coding list.

paragraphs:[

Uterus transplantation for absolute uterine factor infertility is considered not medically necessary. The available evidence is insufficient to demonstrate an improvement in net health outcomes, and therefore the procedure and associated donor/recipient operations are excluded from coverage under this policy. Members and providers should consult the member's specific plan documents (Evidence of Coverage or Subscriber Agreement) for benefit applicability and any applicable limitations.

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The following uterus transplantation and related donor/recipient procedure codes are explicitly designated as not medically necessary / not covered: 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T. These codes are not covered for Medicare Advantage Plans and are not medically necessary for Commercial products.

Billing and codes

Not covered / Not medically necessary CPT Category III codesCPTNot Covered

0664T	Donor hysterectomy (including cold preservation); open, from cadaver donor.
0665T	Donor hysterectomy (including cold preservation); open, from donor living.
0666T	Donor hysterectomy (including cold preservation); laparoscopic or robotic, from donor living.
0667T	Recipient uterus allograft transplantation from cadaver or donor living.
0668T	Backbench standard preparation of cadaver or donor uterine allograft to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary.
0669T	Backbench reconstruction of cadaver or living donor uterus allograft to transplantation; venous anastomosis, each.
0670T	Backbench reconstruction of cadaver or donor uterus allograft to transplantation; arterial.

What providers must do

Prior Authorization

Prior authorization is not applicable for uterus transplantation services under this policy. Providers should still confirm any group- or contract-specific requirements prior to scheduling services.

Prior authorization: Not applicable to this policy
Check group/contract terms for any local prior auth requirements

Documentation Required

Benefit Verification & Documentation

Providers should review member benefits and eligibility through the member's Evidence of Coverage / Subscriber Agreement before providing services. Verify coverage details with the payer's provider call center when in doubt.

Verify member benefits and eligibility against Evidence of Coverage / Subscriber Agreement

Clinical context

Absolute uterine factor infertility (AUFI) refers to infertility caused by an absent or nonfunctional uterus due to congenital, surgical, anatomical, or acquired factors. AUFI therefore precludes carrying a pregnancy without a functional uterus.

Uterus transplantation is a complex, multistage, temporary organ transplant intervention that involves donor hysterectomy and backbench preparation, recipient implantation with subsequent immunosuppression, in vitro fertilization and embryo transfer, pregnancy management, and planned graft removal after childbearing. Although this procedure can allow individuals with AUFI to carry a pregnancy, available evidence has not demonstrated sufficient improvement in net health outcomes to support coverage.

Epidemiologic and outcome data remain limited: AUFI is estimated to affect about 1 in 500 females of childbearing age, and published reports of uterus transplant experience (including surgical success rates, complication rates, and live births) are evolving but currently considered insufficient to establish medical necessity, which is reflected in the policy exclusion.

Key definitions

AUFI definition

TermAbsolute uterine factor infertility (AUFI)

DefinitionInfertility attributable to an absent or non-functional uterus due to congenital, surgical, anatomical, or acquired factors that prevent embryo implantation and term pregnancy.

Examples / causesCongenital (eg, Mayer–Rokitansky–Küster–Hauser [MRKH] syndrome), surgical (eg, hysterectomy), anatomical, or acquired conditions.

Estimated prevalenceApproximately 1 in 500 females of childbearing age.

Clinical noteHysterectomy is the most common cause of acquired AUFI; MRKH accounts for a small proportion of Müllerian anomalies.

Uterus transplantation definition