Blue Cross Blue Shield RI Infertility Coverage Update

Coverage and Medical Necessity Criteria

Eligibility and MET IVF medical necessity

Covered when ALL of the following eligibility and medical necessity criteria are met as specified below.

Eligibility general: Female must have documented inability to conceive after 1 year of unprotected intercourse with sperm exposure (6 months if age >=35). For members who miscarried, prior time attempting to conceive before that pregnancy counts toward the 1-year or 6-month period. Members (male and female) attempting to conceive must be presumably healthy without a history of prior sterilization or sterilization reversal. IVF services are not indicated if postmenopausal state is the cause of infertility unless member is under age 43 with premature ovarian failure.1 year (6 months if >=35)

Duration counts prior attempts before a pregnancy; infertility determination for members without sperm exposure follows separate AI/IUI rules.

IUI prerequisite for IVF when applicable: For female members without a male partner or without exposure to sperm, infertility is determined after 6 artificial insemination (AI) cycles using donor sperm. To qualify for IVF the 6 failed AI cycles must include documented failed medicated IUI cycles as follows: age <35 = 3 medicated IUI cycles; age 35–39 = 2 medicated IUI cycles; age >40 = no medicated IUI cycles required.3/2/0 medicated IUI cycles by age group

All costs for these AI/IUI cycles, including donor sperm procurement/processing/storage, medications and facility/provider charges are at the member's expense; AI cycles with donor sperm are not a covered benefit for establishing the diagnosis.

Medical criteria for Multiple Embryo Transfer (MET): MET is medically necessary when one of the following is met: member <35 with diminished ovarian reserve or prior unsuccessful Single Embryo Transfer (SET); any age with 2 unsuccessful SETs; member age 35 to <38 after an unsuccessful first treatment cycle using own fresh or frozen embryo or after a prior successful IVF cycle followed by one failed SET; or members age >=38 undergoing IVF treatment.age-based and prior SET/failure conditions

Single embryo transfer is preferred to reduce multiple gestation; MET allowed only when conditions above are met.

IVF cycle limit and extension: If a member undergoes 4 IVF cycles (SET or MET) that do not result in pregnancy and delivery, the requesting physician must submit documentation for review to determine approval of further transfer procedures. Required documentation includes: number and type of all past IVF/IUI attempts; details of a revised IVF methodology with a literature-supported predicted success rate; and documentation that the patient has been informed of and accepts the predicted success rate and proposed services.>4 cycles requires documentation

Each embryo transfer procedure (fresh or frozen; single or multiple embryo) is counted as one cycle.

Male infertility and donor gametes

Covered when specific conditions are met:

Male infertility coverage: Services to diagnose and treat male infertility are covered when male infertility has been confirmed. Donor sperm is covered as part of treatment for female infertility when the female eligibility criteria have been met and donor sperm is needed (e.g., no male partner). Donor sperm is also covered for treatment of male infertility when male infertility is confirmed and not the result of prior sterilization.diagnostic confirmation required for male infertility

Services related to procurement of donor sperm are covered; fees associated with collection and finding a donor are not covered.

Donor eggs coverage: Donor eggs (gametes) are covered when the member meets the criteria for services to treat female infertility. If donor eggs are obtained through an egg bank, reimbursement is provided for the cost of the eggs; implantation services related to those eggs are covered.meets female infertility criteria

Charges from egg donation facilitation agencies (facilitation, donor transportation) are not covered.

Fertility preservation (iatrogenic infertility)

Covered when ALL of the following are met:

Fertility preservation for medically induced risk: Retrieval and cryopreservation of eggs, embryos, and sperm are covered when a medically necessary treatment (surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes) may directly or indirectly cause iatrogenic infertility.medical treatment with likely infertility risk per professional guidance

'Iatrogenic infertility' is defined as impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment. Benefits for storage may vary by group/contract; effective as groups renewed in 2020, some storage fees are covered—refer to the member's Evidence of Coverage/Subscriber Agreement for specific benefits.

Medical necessity and not medically necessary categories

Coverage determinations and medical necessity statements in this section:

Medically Necessary Procedures: Blastocyst (extended culture) transfer may be considered medically necessary based on RCTs and meta-analyses showing higher live birth rates compared to cleavage-stage transfer. Intracytoplasmic sperm injection (ICSI) for male factor infertility and cryopreservation of testicular tissue in adult men for use with ICSI are considered medically necessary.

Statements supported by RCTs and clinical reviewer input; ICSI is supported for male factor infertility.

Insufficient Evidence / Not Medically Necessary: Assisted hatching, co-culture of embryos, cryopreservation of ovarian tissue or oocytes, cryopreservation of testicular tissue in prepubertal boys, and storage and thawing of ovarian tissue, oocytes, or testicular tissue have insufficient published data on live birth rates and outcomes and are considered not medically necessary.

Lack of standardized technique and insufficient published outcome data.

Coverage Conditioned on Medical Treatment: Cryopreservation and storage CPT codes for embryos, sperm, and oocytes (eg, 89258, 89259, 89342, 89343, 89346, 89337, 89356, S4027, S4040) are covered only for members undergoing medical treatment that may result in infertility; for other members these codes are not covered. Effective 1/1/20 as groups renew.

Freezing and storage of blood, gametes, sperm, embryos, or other tissues for future use are only covered when performed for iatrogenic infertility (that is, when a medically necessary treatment such as surgery, radiation, chemotherapy, or other therapy is likely to impair fertility). Freezing and storage for indications other than iatrogenic infertility are not covered. Coverage also excludes reversal of voluntary sterilization and infertility treatment for individuals who previously underwent voluntary sterilization, and services for women who meet the definition of normal menopause.

Charges billed by egg donation facilitation agencies — including agency facilitation fees and donor transportation costs — are not covered. Once a donor is identified, clinical services related to egg retrieval, medication, and implantation provided by the participating facility are eligible for coverage and billed by that facility, but facilitation agency administrative expenses and donor travel remain the member’s responsibility.

All services related to a surrogate pregnancy are not covered. This exclusion applies whether the surrogate is a gestational carrier or a traditional surrogate; the policy does not cover procedures or services associated with placing an embryo in and managing a pregnancy carried by a surrogate who is not the plan member.

Coverage, eligibility, and any limits described in this medical policy are subject to the member's subscriber agreement or employer agreement, which supersede this policy. Members and providers should confirm member-specific benefits and any applicable group contract provisions; plan-level limitations may restrict coverage even when services meet medical-necessity criteria in this policy.

Services that do not meet the specified eligibility and medical-necessity criteria in this policy — including the documented infertility duration, required IUI prerequisites where applicable, and the Medical Embryo Transfer (MET) criteria for IVF — are considered not medically necessary and will be denied. Providers should ensure documentation demonstrates that all applicable criteria are satisfied before submission.

The following procedures are considered not medically necessary due to insufficient evidence of benefit in terms of live birth rates and outcomes: assisted hatching; embryo co-culture; cryopreservation of ovarian tissue or oocytes for non‑iatrogenic indications; cryopreservation of testicular tissue in prepubertal boys; and storage and thawing of ovarian tissue, oocytes, or testicular tissue. These techniques lack sufficient published data to support routine coverage.

Services determined to be not medically necessary under this policy, and services that are non-covered benefits under the member's plan, are not payable by the plan. Providers may not bill the member for such services unless the member has been informed in advance and has agreed in writing to accept financial responsibility.

Procedure and Billing Codes

Covered CPT/Procedure Codes (selected)mixedCovered

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

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Covered S-codes and male infertility codesmixedCovered

89272	Extended culture of oocyte(s)/embryo(s), 4-7 days
S4011	In vitro fertilization; complete cycle
S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016	Frozen in vitro fertilization cycle, 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
S4025	Donor services for in vitro fertilization (sperm or embryo), case rate
S4026	Procurement of donor sperm from sperm bank
S4028	Microsurgical epididymal sperm aspiration (MESA)

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Non-covered / Experimental / Related procedure codesmixedNot Covered

0058T	Cryopreservation; reproductive tissue, ovarian
0357T	Cryopreservation; immature oocyte(s)
55400	Vasovasostomy, vasovasorrhaphy
88240	Cryopreservation, freezing and storage of cells, each cell line
88241	Thawing and expansion of frozen cells, each aliquot
89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for PGD); <=5 embryos
89291	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for PGD); >5 embryos
89335	Cryopreservation, reproductive tissue, testicular
89354	Thawing of cryopreserved; reproductive tissue; testicular/ovarian

Covered only when member undergoing medical treatment that may result in infertilitymixedCovered

89258	Cryopreservation; embryo(s)
89259	Cryopreservation; sperm
89342	Storage (per year); embryo(s)
89343	Storage (per year); sperm/semen
89346	Storage (per year); oocyte
89337	Cryopreservation, mature oocyte(s)
89356	Thawing of cryopreserved; oocytes, each aliquot
S4027	Storage of previously frozen embryos
S4040	Monitoring and storage of cryopreserved embryos, per 30

Covered but not separately reimbursedmixedCovered

89352	Thawing of cryopreserved; embryo(s)
89353	Thawing of cryopreserved; sperm/semen, each aliquot
S4037	Cryopreserved embryo transfer, case rate

Diagnostic evaluation services (not part of infertility benefit)mixed

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
89310	Semen analysis; motility and count
89320	Semen analysis; complete
89321	Semen analysis, presence and/or motility of sperm
89322	Semen analysis: volume, count, and differential using strict morphologic criteria
89325	Sperm antibodies (lab)
89329	Sperm evaluation; hamster penetration test

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Unlisted CPT codes for reproductive medicineCPT

89398

Unlisted reproductive medicine laboratory procedure

inv-19: Blastocyst culture duration — > 4 days.

Blastocyst culture duration> 4 days

Associated CPT89272 (Extended culture of oocyte(s)/embryo(s), 4-7 days)

Clinical rationaleEmbryos cultured >4 days progress to blastocyst stage which have higher implantation probability and may reduce high-order multiple pregnancies

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products for in vitro fertilization (IVF) cycles. No prior authorization is required for cycles in which only intrauterine insemination (IUI) is rendered. Providers must follow member-specific benefit and prior authorization requirements; check eligibility and benefit coverage before initiating services.

Prior authorization applies to IVF cycles (SET or MET) — not to IUI-only cycles.
Verify member-specific benefits and prior authorization requirements prior to scheduling.

Billing Rule

Unlisted Procedure Submission and Documentation

When no specific CPT exists for a reproductive medicine procedure (for example TESE/TESA/MESA), submit the claim using CPT 89398 (Unlisted reproductive medicine laboratory procedure) and include supporting documentation per standard unlisted-procedure claim requirements. Providers should include operative notes, indication, and a description of the procedure and rationale for the unlisted code.

Background and Scope

Infertility services encompass diagnostic evaluation and assisted reproductive treatments for the inability to conceive or sustain a pregnancy. Primary treatment modalities addressed in this policy include intrauterine insemination (IUI) and in vitro fertilization (IVF), with IVF performed as either Single Embryo Transfer (SET) or Multiple Embryo Transfer (MET) depending on age, prior treatment response, and other medical criteria. The policy defines medical‑necessity conditions for MET and documents requirements for additional IVF cycles when four prior cycles have not resulted in pregnancy and delivery.

Key Definitions

inv-34: IUI definition — Artificial intrauterine insemination, timing and use of fertility drugs/ultrasound.

DefinitionArtificial intrauterine insemination (IUI): insemination bypasses the cervix so sperm target the ova; often timed with ultrasound

AdjunctsMay be used with transvaginal ultrasound to time follicular development and with fertility drugs to increase pregnancy chance

ContrastICI (intracervical insemination) is rarely used compared to IUI

inv-35: Assisted hatching — mechanical disruption of zona pellucida; evidence summary.

DefinitionAssisted hatching: mechanical disruption of the zona pellucida to facilitate embryo hatching and potentially improve implantation

Evidence summaryRandomized controlled trials and meta-analyses have not shown a significant improvement in live birth rate; some meta-analyses show improved clinical pregnancy rate

OpenPayer

Infertility Services (IUI, IVF, donor gametes, fertility preservation)

Coverage and Medical Necessity Criteria

Procedure and Billing Codes

Prior Authorization, Documentation, and Billing Guidance

Background and Scope

Key Definitions