Infertility Services (IUI, IVF, donor gametes, fertility preservation)
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Coverage and medical necessity criteria for diagnosis and treatment of female and male infertility including IUI, IVF (SET/MET), donor eggs/sperm, and fertility preservation for iatrogenic infertility; affects BCBSRI members and providers submitting claims or prior authorization for these services.
No material clinical or coverage changes in this revision.
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.
Duration counts prior attempts before a pregnancy; infertility determination for members without sperm exposure follows separate AI/IUI rules.
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.
Single embryo transfer is preferred to reduce multiple gestation; MET allowed only when conditions above are met.
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:
Services related to procurement of donor sperm are covered; fees associated with collection and finding a donor are not covered.
Charges from egg donation facilitation agencies (facilitation, donor transportation) are not covered.
Fertility preservation (iatrogenic infertility)
Covered when ALL of the following are met:
'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:
Statements supported by RCTs and clinical reviewer input; ICSI is supported for male factor infertility.
Lack of standardized technique and insufficient published outcome data.
Coverage for storage may vary by group/contract; refer to Evidence of Coverage.
Explicit exclusion of surrogate-related services.
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
| 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 |
| 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) |
| 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 |
| 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 |
| 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 |
| 89398 | Unlisted reproductive medicine laboratory procedure |
Prior Authorization, Documentation, and Billing Guidance
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.
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.
- Use CPT 89398 for TESE, TESA, MESA, hyaluronan binding assay, and other unlisted reproductive medicine laboratory procedures.
- Attach clinical documentation and itemized operative/procedure details to support medical necessity when filing an unlisted code.
Coverage Limited by Indication
Certain cryopreservation and storage services are covered only for members undergoing medical treatment that may result in infertility (for example gonadotoxic therapy). For all other members these cryopreservation and storage CPT/HCPCS codes are not covered under the infertility benefit.
Documentation Required for Additional IVF Cycles
After four IVF embryo transfer cycles (single or multiple embryo transfers) that do not result in pregnancy and delivery, the requesting physician must provide documentation for review to determine if additional transfer procedures will be approved. Documentation must include the number and type of all past IVF/IUI attempts, details of a revised IVF methodology with expected success rate supported by literature, and confirmation the patient has been informed of and accepts the predicted success rate.
- The policy counts each embryo transfer procedure (fresh or frozen, SET or MET) as one cycle toward the 4-cycle limit.
- Submit prior cycle details, revised treatment plan with literature support, and patient counseling/acceptance documentation when requesting >4 cycles.
Coding and Reporting Note
BCBSRI-participating facilities primarily use 'S' codes when reporting infertility/IVF services. Providers should report the applicable S- and CPT-codes when benefit and medical necessity criteria are met. Some male infertility services listed (e.g., 55870) do not require preauthorization. Ensure coding accurately reflects the service performed and submit appropriate supporting documentation for case-rate S-codes or unlisted CPTs as applicable.
- Use S4011, S4015, S4016, S4020–S4042, etc., for complete and case-rate IVF reporting where applicable.
- Male infertility services (example: 55870) are covered and may not require preauthorization — verify specific code requirements.
- When submitting S-codes or unlisted CPT 89398, include clinical documentation to support medical necessity and the level of service billed.
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
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