Expanded Fertility Services (Medical Coverage Policy)
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Defines coverage, prior authorization, and medical necessity criteria for expanded assisted reproductive technologies and related services for members with employer-purchased expanded fertility coverage through Blue Cross & Blue Shield of Rhode Island.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Infertility definition and IVF qualification for Members AFAB
Covered when ALL of the following are met
Medicated IUI cycle requirements: members under 40 = 2 medicated IUI cycles; members 40 and older = 0 medicated IUI cycles.
Requests for members with prior sterilization undergo clinician review and may be administratively excluded.
Amenorrhea with elevated FSH after age 42 is considered equivalent to normal menopause and excluded.
Medical necessity criteria for Multiple Embryo Transfer (MET)
MET is covered when ONE of the following criteria is met
Infertility diagnosis is not required for MET when one of these criteria is met.
Single Embryo Transfer (SET) prior auth and cycle policy
SET policy and limits
If pursuing additional cycles beyond 4 total embryo transfer cycles, additional medical documentation/criteria apply.
Transfers can be fresh or frozen; a new cycle begins with the next embryo transfer if pregnancy not achieved.
Cryopreservation coverage
Covered when used for treatment of infertility or iatrogenic infertility; elective preservation covered with limits
For infertility indications there is no lifetime retrieval limit; iatrogenic infertility includes impairment from surgery, radiation, chemotherapy, or other medical treatment (including gender-affirming services).
Claims for elective fertility preservation must be submitted with primary diagnosis code Z31.84 to ensure correct processing.
Donor gametes coverage
Covered donor gamete uses
Services provided by egg donation facilitation agencies (e.g., facilitation fees, donor transportation) are not covered.
Cryopreservation of donor sperm includes retrieval, freezing, storage, monitoring, shipping and thawing.
ICSI and sperm retrieval
Covered when ALL of the following are met
Clinical reviewers support ICSI and cryopreservation of testicular tissue in adults with azoospermia; MicroTESE is preferred for production-related azoospermia.
Blastocyst transfer
Covered when ALL of the following are met
Supported by evidence and clinical input showing higher live birth rates with blastocyst transfer.
Adjunct embryo techniques
Evidence summary / coverage stance
Coverage stance should reflect limited evidence for live birth improvement.
Co-culture lacks sufficient evidence to be considered medically necessary.
Elective fertility preservation
Covered when ALL of the following are met
Applies to applicable self-funded groups; benefit booklets may vary by group.
Coverage categories and medical necessity grouping
Coverage stance organized by condition and diagnosis:
Elective preservation is limited to 3 cycles and requires primary diagnosis Z31.84 on claims when applicable.
Providers must follow the payer's medical necessity determination and prior authorization process where required.
Diagnostic services used to evaluate infertility may be billed separately and are not considered part of the infertility benefit.
Unlisted reproductive laboratory procedures may be billed using CPT 89398 where applicable.
Services provided by egg donation facilitation agencies (for example, facilitation fees and donor transportation) are not covered. These agency charges are considered administrative/contractual facilitation and are not related to the clinical egg donation services. Once a donor is identified, clinical services performed by the participating facility (including egg retrieval and related medications) may be billed and considered separately under the policy.
Fertility treatments are excluded for members who have previously undergone a sterilization procedure unless a clinician review finds medical certainty that the prior sterilization is not related to the current inability to conceive or sustain pregnancy. Requests for services in members with prior sterilization will undergo clinician review; if the contractual exclusion applies, the determination is an administrative denial (not a medical necessity denial).
Services to treat fertility are excluded for members who have undergone normal menopause. The policy considers amenorrhea with an elevated follicle stimulating hormone (FSH) level after age 42 to be equivalent to normal menopause; menopause occurring before age 42 is not considered normal menopause under this policy.
Cell storage is covered on an annual basis up to 12 months (one year) per benefit year. Claims for multiyear storage or storage beyond 12 months are not covered under this policy; annual storage claims may be submitted once per benefit year and month-to-month billing is permitted for that year.
Normal menopausal status is an explicit exclusion: fertility treatment services are not covered when the member has undergone normal menopause (amenorrhea with elevated FSH after age 42). In addition, services related to pregnancy carried by a surrogate are excluded when the surrogate is not a member of this plan; such surrogate-related services should not be billed to the plan.
Certain procedures and laboratory codes are specifically listed as not covered. Examples include CPT 55400 (vasovasostomy, vasovasorrhaphy) and listed cryopreservation/expansion cell codes such as 88240 and 88241. When services have no specific CPT, providers may consider using 89398 for unlisted reproductive medicine laboratory procedures, but the listed non-covered codes may be denied.
The Hyaluronan Binding Assay for sperm evaluation is designated not medically necessary for Commercial Products due to insufficient evidence of improved net health outcomes; this assay therefore should not be relied on as a covered diagnostic to support infertility treatment claims. Note that some reproductive laboratory services lack specific CPT codes and may be billed with 89398 where appropriate.
Embryo co-culture techniques are not supported as medically necessary: there is no standardized co-culture method and no controlled trials demonstrating improved implantation or pregnancy rates. Because controlled evidence is lacking, embryo co-culture is considered not covered / not supported by the policy.
Coverage is contingent on a medical necessity determination. Services determined to be not medically necessary under this policy may be denied and, unless the provider has obtained the member's informed written agreement in advance, may not be billed to the member. Benefit eligibility and payment remain subject to the member's subscriber agreement, employer contract, and applicable benefit booklet.
Billing Codes, Limits and Diagnostics
| Z31.84 | Encounter for fertility preservation procedure |
| 58970 | Follicle puncture for oocyte retrieval, any method |
| 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 days; with co-culture of oocyte(s)/embryo(s) |
| 89253 | Assisted embryo hatching, microtechniques (any method) |
| 89254 | Oocyte identification from follicular fluid |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes |
| S4011 | In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination |
| Z31.84 | Encounter for fertility preservation procedure |
| 58970 | Follicle puncture for oocyte retrieval, any method |
| Z31.84 | Encounter for fertility preservation procedure (diagnosis required for elective preservation claims) |
| 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 days; 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; identification and incubation of mature oocytes, fertilization, incubation and visualization |
| S4013 | Complete cycle, GIFT, case rate |
| S4014 | Complete cycle, ZIFT, case rate |
| S4015 | Complete IVF cycle, not otherwise specified, case rate |
| S4016 | Frozen IVF cycle, case rate |
| S4017 | Incomplete cycle, treatment cancelled prior to stimulation, case rate |
| S4018 | Frozen embryo transfer procedure cancelled before transfer, case rate |
| S4020 | In vitro fertilization procedure cancelled before aspiration, case rate |
| S4021 | In vitro fertilization procedure cancelled after aspiration, case rate |
| S4022 | Assisted oocyte fertilization, case rate |
| S4042 | Management of ovulation induction, per cycle |
| 58321 | Artificial insemination; intra-cervical |
| 58322 | Artificial insemination; intra-uterine |
| 58323 | Sperm washing for artificial insemination |
| 89260 | Sperm isolation; simple prep |
| 89261 | Sperm isolation; complex prep |
| S4035 | Stimulated intrauterine insemination (IUI), case rate |
| 89255 | Preparation of embryo for transfer (any method) |
| 89268 | Insemination of oocytes |
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days |
| 89325 | Sperm antibodies (lab) |
| 89335 | Cryopreservation, reproductive tissue, testicular |
| 89354 | Thawing of cryopreserved; reproductive tissue; testicular/ovarian |
| 89258 | Cryopreservation; embryo(s) |
| 89259 | Cryopreservation; sperm |
| 89337 | Cryopreservation, mature oocyte(s) |
| 89342 | Storage (per year); embryo(s) |
| 89343 | Storage (per year); sperm/semen |
| 89346 | Storage (per year); oocyte |
| 89356 | Thawing of cryopreserved; oocytes, each aliquot |
| S3655 | Antisperm antibodies test (immunobead) |
| 55400 | Vasovasostomy, vasovasorrhaphy (non-covered) |
| 88240 | Cryopreservation, freezing and storage of cells (listed as non-covered) |
| 88241 | Thawing and expansion of frozen cells, each aliquot (listed as non-covered) |
| 89398 | Unlisted reproductive medicine laboratory procedure (may be used for services without specific CPT) |
Authorization, Documentation and Claims Instructions
Obtain prior authorization for SET, MET, and post‑4‑cycle transfers
Prior authorization is required for IVF cycles with Single Embryo Transfer (SET) for cycle tracking, for Multiple Embryo Transfer (MET) IVF cycles, and for transfers after four IVF cycles that did not result in pregnancy and delivery; no prior authorization is needed for cycles where only IUI is performed.
- SET prior authorization is for cycle tracking only (no diagnosis required initially).
- Prior authorization is required for MET cycles.
- After 4 IVF cycles without pregnancy/delivery, prior authorization with additional documentation is required.
Use listed fertility procedure codes; 58970 covered without preauth
Submit preauthorization or claims using the listed procedure and S‑codes per policy. Note that CPT 58970 (follicle puncture for oocyte retrieval) is covered for Commercial Products and does not require preauthorization.
- Codes listed as medically necessary must meet the policy's medical necessity criteria to be covered.
- 58970 is covered and no preauthorization is required for Commercial Products (elective preservation requires diagnosis Z31.84).
Ensure medical necessity criteria met before using IVF/S‑codes
Bill and request authorization only for the procedure and S‑codes identified as medically necessary when the policy's medical necessity criteria are met (examples include 58974, 58976, 76948, 89250–89254, 89280–89281, and S4011; see policy code lists). Prior authorization requirements apply per the payer's medical necessity process.
- These CPT and HCPCS S‑codes are designated medically necessary when medical necessity criteria are satisfied.
- Follow the payer's medical necessity/prior authorization process for these services.
Document required medicated IUI attempts before IVF for AFAB members
For AFAB members lacking sperm exposure, require attempted medicated IUI cycles before IVF: members under 40 must have 2 documented medicated IUI cycles; members 40 and older have no medicated IUI requirement.
- For AFAB members without sperm exposure, infertility is determined after 3 AI/IUI cycles; qualifying IUI requirements: under 40 = 2 medicated IUI cycles; 40+ = none.
- Costs for the three AI/IUI cycles (medications, professional, technical, facility) are covered.
Confirm group allows elective IVF without infertility diagnosis
For self-funded employer groups that purchased expanded fertility coverage, IVF cycles and freezing/storage of the member's own cells may be allowed without a diagnosis of infertility; follow the group's benefit booklet for applicability.
- Elective IVF and freezing/storage of own cells are not contingent upon an infertility diagnosis for applicable self‑funded employer clients.
- Benefit booklet/plan terms may vary by group—confirm group applicability.
Limit cryopreservation/donor/procurement codes to members meeting infertility definition
Certain cryopreservation, storage, donor, and procurement services (e.g., 89335, 89258–89259, 89337, 89342–89346, S4027, S4030–S4031, S4040) are covered only for members who meet the policy definition of infertility; do not bill these infertility‑limited codes for members who do not meet infertility criteria unless group benefits allow otherwise.
- Cryopreservation, storage, donor procurement and related codes are conditional — covered only when member meets infertility definition.
- Diagnostic services to evaluate infertility may be billed separately.
Provide detailed documentation for review after 4 unsuccessful IVF cycles
After four consecutive IVF cycles (SET or MET) that do not result in pregnancy and delivery, the requesting physician must provide documentation of prior IVF/IUI attempts, a revised IVF methodology with predicted success rate supported by literature, and documentation that the member was informed and consents to the proposed services.
- Provide the number and type of all past IVF/IUI attempts.
- Submit details of revised IVF methodology and literature‑supported predicted success rate.
- Document that the member was informed of predicted success and consents.
Use Z31.84 as primary diagnosis for elective preservation claims
When services are performed for elective fertility preservation, submit claims with PRIMARY diagnosis code Z31.84 (Encounter for fertility preservation procedure).
- Z31.84 must be used as the primary diagnosis on claims for elective preservation to ensure correct processing and coordination of benefits.
- This diagnosis should not be used for members who meet the policy definition of infertility.
Document two semen analyses showing severe male infertility thresholds
For AMAB members, document severe male infertility on two semen analyses meeting the specified thresholds: <10 million total motile sperm/ejaculate (pre‑wash), or <3 million total motile sperm (post‑wash), or ≤2% normal forms (Strict Kruger).
- Two semen analyses must show one of the listed severe infertility thresholds.
- Use these results to support coverage for male infertility‑related services (e.g., ICSI, sperm retrieval).
File elective preservation claims with primary diagnosis Z31.84 (3‑cycle limit)
Claims for services performed for elective fertility preservation (limited to 3 cycles per lifetime) must be submitted with a primary diagnosis of Z31.84 to ensure correct claims processing and coordination of benefits.
- Elective fertility preservation is limited to 3 cycles per lifetime.
- Use Z31.84 as the primary diagnosis on claims for elective preservation cycles.
Code oocyte retrieval for elective preservation with Z31.84; observe 3‑cycle limit
When performing oocyte retrievals for elective fertility preservation (egg/oocyte retrieval limited to 3 cycles per lifetime), submit claims with primary diagnosis Z31.84; many IVF‑related codes are listed as covered or medically necessary when criteria are met—follow coding guidance in the policy.
- Oocyte retrieval for elective preservation (CPT 58970) is covered without preauthorization for Commercial Products but must include Z31.84 for elective use.
- Ensure other IVF codes billed are supported by applicable medical necessity or elective preservation coding rules.
Anticipate clinician review and possible administrative denial for prior sterilization
Requests for fertility services for members with previous sterilization will undergo clinician review; if the clinician determines the contractual exclusion applies (i.e., inability may be related to prior sterilization), the request will be administratively denied.
- Clinician review will assess whether prior sterilization is related to current infertility.
- A determination that the contractual exclusion applies results in an administrative denial, not a medical necessity review.
Do not expect coverage for fertility services after normal menopause (FSH/amenorrhea)
Services to treat fertility are excluded for members who have undergone normal menopause (amenorrhea and elevated FSH after age 42 considered equivalent); such exclusions may result in denial.
- Menopause prior to age 42 (premature ovarian failure) is not considered normal menopause under this policy.
- If member has amenorrhea and elevated FSH after age 42, fertility services are excluded.
Do not bill for surrogate‑related services when surrogate is not a plan member
All services related to surrogacy are excluded from coverage when the surrogate is not a plan member; do not submit claims for surrogate‑related services for non‑member surrogates.
- Gestational or traditional surrogacy services are excluded if the surrogate is not a member of the plan.
- Exclusion applies to all services related to surrogate parents.
Confirm menopausal status—normal menopause excludes coverage
Services to treat fertility are excluded for members who have undergone normal menopause (including amenorrhea with elevated FSH after age 42); such exclusions may lead to denial of services billed for infertility treatment.
- Amenorrhea with elevated FSH after age 42 is considered equivalent to normal menopause and excluded.
- Confirm menopausal status when assessing eligibility for fertility services.
Ensure primary diagnosis Z31.84 is used for elective preservation claims
Claims for elective fertility preservation must be submitted with primary diagnosis Z31.84; incorrect coding (failure to use Z31.84 as primary diagnosis) may lead to improper claims processing or coordination of benefits.
- Z31.84 is required as the primary diagnosis for elective preservation claims to ensure correct processing.
- Do not use Z31.84 for members who meet the policy definition of infertility.
Do not bill CPT 55400 (vasovasostomy) and listed non‑covered cell cryopreservation codes
Vasovasostomy (CPT 55400) and certain listed cryopreservation/expansion cell codes are non‑covered and may be denied; if 55400 is performed for reasons other than reversal of sterilization it may be reviewed by a clinician but is generally non‑covered.
Policy Background and Scope
Assisted reproductive technologies (ART) encompass procedures in which eggs or embryos are handled outside the body and include services such as gamete and embryo cryopreservation, in vitro fertilization (IVF), embryo transfer techniques, donor gametes, and gestational surrogacy. This policy applies to members whose employer has purchased expanded fertility coverage and supplements standard infertility benefits by defining medical necessity, prior authorization requirements, coverage limits (for example, elective fertility preservation limited to 3 cycles per lifetime for applicable groups), and exclusions specific to these expanded benefits.
Key Terms and Definitions
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