Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial products. No prior authorization is required for cycles in which only artificial intrauterine insemination (IUI) is rendered. Providers should obtain prior authorization per payer instructions before initiating IVF case-rate S-coded services when applicable.

• Prior authorization required for Medicare Advantage Plans; recommended for Commercial products.
• No prior authorization needed for IUI-only cycles.
• Preauthorization expectations apply to many IVF case-rate S-codes (see medically necessary procedure codes).

Medically Necessary Procedure Codes

The following CPT and HCPCS/S codes are considered medically necessary under the member's infertility benefit when the eligibility and medical necessity criteria are met. Facilities participating with BCBSRI commonly report infertility/IVF services using S-codes; documentation must support medical necessity.

• CPT: 58970 (follicle puncture for oocyte retrieval), 58974 (embryo transfer), 58976 (GIFT/ZIFT), 76948 (ultrasonic guidance), 89250, 89251, 89253, 89254, 89280, 89281.
• HCPCS/S-codes: S4011, S4013, S4014, S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4023, S4025, S4042.
• Cryopreservation/storage codes (89258, 89259, 89335, 89337, 89342, 89343, 89346, 89354, 89356) are medically necessary only when iatrogenic infertility criteria are met; otherwise not covered.

Cryopreservation Conditional Coverage

Cryopreservation and long-term storage services are covered only when the medical necessity criteria for iatrogenic infertility (e.g., fertility preservation due to medically necessary gonadotoxic treatment) have been met. For members who do not meet iatrogenic infertility criteria, these services are not covered.

• Covered when iatrogenic infertility criteria met: 89258 (embryo cryopreservation), 89259 (sperm cryopreservation), 89335 (testicular tissue cryopreservation), 89337 (oocyte cryopreservation), 89342/89343/89346 (storage per year), 89354/89356 (thawing).
• Storage of previously frozen embryos is subject to the same iatrogenic infertility requirement.

Step / First-line Services

Certain lower-complexity infertility services are included in the infertility benefit and do not require prior authorization. These 'step' or first-line services should be used and documented as appropriate before moving to higher-complexity interventions when eligibility criteria require it.

• Covered without preauthorization: 55870 (electroejaculation), 58321 (artificial insemination; intra-cervical), 58322 (artificial insemination; intra-uterine), 58323 (sperm washing for AI), 89257 (sperm identification from aspiration), 89260/89264 (sperm prep and related tests), S4026 (procurement of donor sperm), S4030/ S4031 (sperm procurement & cryopreservation visits), S4035 (stimulated IUI case rate).
• Some services are covered but not separately reimbursed (e.g., 89255, 89268, 89272, 89352, 89353, S4037).

Prior Sterilization Exclusion

Requests for infertility services for members with prior sterilization will be administratively denied under the contractual exclusion unless there is clear medical certainty that the prior sterilization is not related to the present inability to conceive or sustain pregnancy. Such cases undergo clinician review; administrative denials are not medical necessity reviews.

• Prior sterilization is a contractual exclusion for infertility services.
• Exceptions require documentation demonstrating prior sterilization is unrelated to current infertility; clinician review will occur.

Eligibility Criteria Not Met — Denial Risk

Services that do not meet the eligibility criteria for AFAB or AMAB members will be denied as not covered / not medically necessary. Providers must confirm and document that members meet the specified fertility eligibility criteria before providing or billing for IVF services.

• Members AFAB must meet duration-of-infertility requirements, age-specific IUI/AI trial requirements when no sperm exposure exists, absence of prior sterilization, and absence of postmenopausal state as the cause (with limited premature ovarian failure exception).
• Members who do not meet these eligibility criteria: services are not covered and will be denied as not medically necessary.

Documentation Required After 4 Failed IVF Cycles

After four IVF cycles (each embryo transfer—fresh or frozen—counts as one cycle) that do not result in pregnancy and delivery, the requesting physician must submit documentation for review before additional transfer procedures will be approved. All required items must be provided.

• Documentation of the number and type of all past IVF and IUI attempts (including whether transfers were SET or MET, fresh or frozen).
• Details of a revised IVF methodology with supporting literature estimating predicted success rate using the revised methodology.
• Documentation that the patient was informed of the predicted success rate and accepts the proposed services.
• For cycle-limit purposes, each embryo transfer (single or multiple) is considered one cycle; if pregnancy is not achieved, a new cycle begins with the next embryo transfer.

IVF Service Documentation

A typical IVF cycle includes multiple components that should be documented and billed appropriately: stimulation/medication, monitoring (labs/imaging), egg retrieval, laboratory fertilization procedures (including ICSI, culture, assisted hatching), embryo transfer, and post-transfer monitoring/support. Providers should ensure complete clinical documentation to support medical necessity and chosen procedure codes.

• IVF cycle steps to document: controlled ovarian hyperstimulation, egg retrieval (CPT 58970), in vitro fertilization/ICSI procedures (89280/89281), embryo culture (89250/89251/89272), assisted hatching (89253), embryo transfer (CPT 58974 or S4011), and monitoring/support (S4042, labs, imaging 76948).
• BCBSRI facilities commonly report case rates using S-codes for complete/incomplete/frozen cycles (S4013–S4023, S4025, etc.).

Single Embryo Transfer Preference

Elective single embryo transfer (SET) is the preferred approach to reduce multiple gestations and is associated with improved perinatal outcomes in appropriately selected patients. Providers should discuss SET with members and document counseling and the rationale for SET versus multiple embryo transfer when applicable.

• SET reduces risks of multiple gestations and is associated with higher rates of good perinatal outcomes in selected age groups (<35 and 35–37 with favorable prognosis).
• Document patient counseling, prognosis, and member acceptance if MET (multiple embryo transfer) is pursued.