Infertility Services (IUI, IVF) Medical Coverage Policy
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts
Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
Defines medical necessity criteria, coverage, exclusions, prior authorization, and state-mandated requirements for assisted reproductive services (IUI, IVF), donor gametes, and fertility preservation for members of Blue Cross Blue Shield of Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria and Medical Necessity
IVF / MET medical necessity and general IVF eligibility
Covered when ALL of the following are met as specified below
General eligibility
- Duration or AI criteria: For female members without male partners or without exposure to sperm, infertility is determined after 6 artificial insemination (AI) cycles using donor sperm; the 6 failed AI cycles must include the following number of documented failed medicated IUI cycles to qualify for IVF: <35 years = 3 medicated IUI cycles; 35–39 years = 2 medicated IUI cycles; >=40 years = 0 medicated IUI cycles. All costs associated with these AI/IUI cycles (including donor sperm procurement, processing, storage, medications, and professional/facility charges) are the member's responsibility.
MET medical necessity
- Listed MET indications: Members <35 years with diminished ovarian reserve or prior unsuccessful Single Embryo Transfer (SET); members of any age who have undergone 2 unsuccessful SETs using donor eggs; members 35 to <38 years who have had either an unsuccessful first treatment cycle using their own fresh or frozen embryo or a prior successful IVF cycle followed by one failed SET; members >=38 years undergoing IVF treatment.
Donor gametes and fertility preservation
Procedure-specific coverage determinations
Coverage determinations as stated in the document:
see evidence summary
see clinical rationale
insufficient evidence for effectiveness
The policy excludes certain services from coverage. Specifically, freezing and storage of blood, gametes, sperm, embryos, or other tissues for future use are listed as not covered. Also excluded are reversal of voluntary sterilization, infertility treatment for individuals with prior voluntary sterilization, services for women who meet the definition of normal menopause, and surrogate parenting or any services related to surrogate pregnancy. Providers should verify member-specific benefits as subscriber/employer agreements supersede this policy and may affect coverage determinations.
Charges from egg donation facilitation agencies, including agency facilitation or contractual fees and donor transportation costs, are not covered because they are not considered services directly related to the medical provision of egg donation. Once a donor is identified, clinical services such as egg retrieval, medications, and implantation-related procedures provided by the participating facility are covered and should be billed by that facility.
All services associated with surrogate pregnancy are not covered. This includes situations where an embryo is placed in a woman other than the member (gestational or traditional surrogacy). The policy explicitly states that surrogate parenting and all related services are excluded from coverage.
Certain cryopreservation and storage CPT/HCPCS codes are identified as not covered in specified contexts. While many cryopreservation procedures may be covered when medically indicated, the policy notes exclusions for storage-related codes (e.g., long-term storage billing) and indicates that CPT codes for storage may be excluded. Providers should follow coding guidance and verify member benefits prior to billing storage charges.
Services that do not meet the policy's specified medical criteria are considered not medically necessary and therefore not covered. Testing to diagnose infertility is a covered service, but infertility treatments (IUI, IVF with SET or MET) that fail to meet eligibility criteria may be denied. Providers should confirm eligibility and prior authorization requirements when applicable and be aware that benefits are governed by the member's subscriber or employer agreement.
In vitro fertilization services that do not meet the stated medical criteria in this policy are considered not medically necessary. The policy also identifies specific reproductive procedures—assisted hatching, embryo co-culture, cryopreservation of ovarian tissue or oocytes, and cryopreservation of testicular tissue in prepubertal boys—as not medically necessary due to insufficient evidence of improved live birth or long-term outcomes.
The policy lists several procedures as not medically necessary because current evidence is insufficient to support improved live birth or long-term outcomes. These include assisted hatching, which randomized trials and meta-analyses have not shown to significantly improve live birth rates; embryo co-culture, for which no standardized method or controlled trials demonstrate improved outcomes; and cryopreservation procedures for ovarian tissue or oocytes and cryopreservation of testicular tissue in prepubertal boys.
When services are determined to be not medically necessary—or when a medically necessary service is nonetheless a non-covered benefit—payment is not guaranteed. The policy reminds providers that benefits and eligibility are defined by the member's subscriber certificate or employer agreement and that providers may not bill members for non-covered care unless the member provided prior written agreement to accept financial responsibility.
Coding and Billing (CPT/S/Codes)
| 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; <= 10 oocytes |
| 89281 | Assisted oocyte fertilization, microtechnique; >10 oocytes |
| 89255 | Preparation of embryo for transfer (any method) |
| 89268 | Insemination of oocytes |
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days |
| S4011 | In vitro fertilization; including identification and incubation of mature oocytes, fertilization, incubation of embryo(s), visualization |
| S4013 | Complete cycle, gamete intrafallopian transfer (GIFT), case rate |
| S4014 | Complete cycle, zygote intrafallopian transfer (ZIFT), case rate |
| S4015 | Complete in vitro fertilization cycle, not otherwise specified, case rate |
| S4016 | Frozen in vitro fertilization cycle, case rate |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes |
| 89255 | Preparation of embryo for transfer (any method) |
| 89268 | Insemination of oocytes |
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days |
| 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 of development |
| S4013 | Complete cycle, gamete intrafallopian transfer (GIFT), case rate |
| S4014 | Complete cycle, zygote intrafallopian transfer (ZIFT), case rate |
| S4015 | Complete in vitro fertilization cycle, not otherwise specified, case rate |
| S4016 | Frozen in vitro fertilization cycle, case rate |
| 55870 | Electroejaculation |
| 58321 | Artificial insemination; intra-cervical |
| 58322 | Artificial insemination; intra-uterine |
| 58323 | Sperm washing for artificial insemination |
| 89257 | Sperm identification from aspiration (other than seminal fluid) |
| 89260 | Sperm isolation; simple prep |
| 89261 | Sperm isolation; complex prep |
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved |
| S3655 | Antisperm antibodies test (immunobead) |
| S4026 | Procurement of donor sperm from sperm bank |
| 0058T | Cryopreservation; reproductive tissue, ovarian |
| 0357T | Cryopreservation; immature oocyte(s) |
| 55400 | Vasovasostomy/vasovasorrhaphy |
| 88241 | Thawing and expansion of frozen cells, each aliquot |
| 89258 | Cryopreservation; embryo(s) |
| 89259 | Cryopreservation; sperm |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique; <=5 embryos |
| 89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique; >5 embryos |
| 89335 | Cryopreservation, reproductive tissue, testicular |
| 89342 | Storage (per year); embryo(s) |
| 55200 | Vasotomy, cannulization with or without incision of Vas |
| 58750 | Tubotubal anastomosis |
| 88349 | Electron microscopy; scanning (lab) |
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (lab) |
| 89310 | Semen analysis; motility and count (lab) |
| 89320 | Semen analysis; complete (volume, count, motility and differential) (lab) |
| 89321 | Semen analysis; presence and/or motility of sperm |
| 89322 | Semen analysis: volume, count, and differential using strict morphologic criteria (lab) |
| 89325 | Sperm antibodies (lab) |
| 89329 | Sperm evaluation; hamster penetration test (lab) |
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization and Benefits Verification
Prior authorization is required for in vitro fertilization (IVF) cycles for BlueCHiP for Medicare and is recommended for Commercial products. No prior authorization is required for cycles in which only intrauterine insemination (IUI) is rendered. Providers should verify member-specific benefits and eligibility with the member's subscriber or employer agreement and contact the provider call center for confirmation prior to rendering services.
- Prior auth required for IVF cycles (BlueCHiP for Medicare); recommended for Commercial products
- No prior auth needed for IUI-only cycles
- Verify member benefits and eligibility with subscriber/employer agreement and provider call center
Preauthorization for Male Infertility Services
The following listed male infertility service codes do not require preauthorization when billed by BCBSRI-participating facilities. Note that BCBSRI-participating facilities primarily use 'S' codes when reporting infertility/IVF services.
- 55870 Electroejaculation
- 58321 Artificial insemination; intra-cervical
- 58322 Artificial insemination; intra-uterine
- 58323 Sperm washing for artificial insemination
- 89257 Sperm identification from aspiration (other than seminal fluid)
- 89260 Sperm isolation; simple prep
- 89261 Sperm isolation; complex prep
- 89264 Sperm identification from testis tissue
- S3655 Antisperm antibodies test (immunobead)
- S4026 Procurement of donor sperm from sperm bank
- S4028 Microsurgical epididymal sperm aspiration (MESA)
- S4030 Sperm procurement and cryopreservation; initial visit
- S4031 Sperm procurement and cryopreservation; subsequent visit
- S4035 Stimulated intrauterine insemination (IUI), case rate
Coverage Denial for Not Meeting Eligibility
Services to treat female infertility (IUI and IVF) will be denied as not covered when the member does not meet the policy’s eligibility criteria. Examples include inadequate duration of unprotected intercourse or failure to complete required AI/IUI attempts where applicable. Requests for infertility services for members with prior sterilization will be administratively denied if the inability to conceive may be related to that sterilization, unless clinical review determines the exclusion does not apply.
- Services not meeting eligibility criteria are non-covered benefits and will be denied
- Prior sterilization may result in administrative denial; clinician review required to overturn
Potential Denial for Storage and Unlisted Coding
Storage-related CPT/HCPCS codes (cryopreservation, freezing and storage) and certain unlisted procedures may be identified as non-covered. For members undergoing medical treatment that may result in infertility, most services are covered except for CPT codes for storage; providers should expect potential denial for storage and for claims with unlisted or unsupported procedure coding.
- Non-covered examples: 0058T Cryopreservation; reproductive tissue, ovarian
- 0357T Cryopreservation; immature oocyte(s)
- Codes for cryopreservation, freezing and storage and related thawing/expansion (e.g., cryopreservation and storage CPTs)
Documentation Required After Four Unsuccessful IVF Cycles
After four IVF cycles (single or multiple embryo transfers) that do not result in pregnancy and delivery, the requesting physician must provide documentation for clinical review before further transfer procedures will be approved.
- Documentation of the number and type of all past IVF/IUI attempts
- Details of a revised IVF methodology and literature-supported predicted success rate
- Documentation that the patient was informed of the predicted success rate and consents to the proposed services
Baseline Eligibility Documentation
Baseline eligibility documentation must demonstrate the duration of infertility (generally 1 year of unprotected intercourse, or 6 months if the female member is ≥35), or completion of the required artificial insemination cycles for members without male partners. For AI cycles with donor sperm, the six failed cycles must include the required number of documented failed medicated IUI cycles prior to IVF eligibility.
- Documented inability to conceive after 1 year of unprotected intercourse (or 6 months if ≥35)
- For members without exposure to sperm: inability to conceive after 6 AI cycles (donor sperm); these are not covered and costs are member’s responsibility
- Required failed medicated IUI cycles prior to IVF: <35 years = 3 cycles; 35–39 years = 2 cycles; ≥40 years = no medicated IUI requirement
IUI Trial Requirement Before IVF
Female members must complete the policy-specified number of failed medicated IUI cycles before IVF is eligible: three medicated IUI cycles for those younger than 35, two for ages 35–39, and none required for those 40 or older. All costs associated with these IUI cycles (including donor sperm procurement, processing, storage, medications, and professional/facility charges) are the member's responsibility when donor sperm is used.
- IUI trial requirement before IVF: <35 years = 3 medicated IUI cycles; 35–39 years = 2 medicated IUI cycles; ≥40 years = no medicated IUI cycles required
- All costs for the six AI/IUI cycles with donor sperm are the member’s responsibility
Background and Scope
Background: This policy addresses diagnosis and treatment of infertility and assisted reproductive technologies, including IUI and IVF, use of donor gametes, and fertility preservation when medically indicated (for example, when planned medical treatment may cause iatrogenic infertility). Definitions provided include IUI (intrauterine insemination), assisted hatching, and blastocyst transfer (extended culture > 4 days). The policy references national data on embryo transfer practices and outcomes and notes Rhode Island statutory requirements that may apply to coverage for infertility care.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.