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.

ModifiedCentenePolicy CP.MP.55

Assisted Reproductive Technology

Customize your policy alerts

Sign up for Centene Policy CP.MP.55 alerts

Get alerted when Policy CP.MP.55 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity criteria, covered and not medically necessary assisted reproductive technologies (ART) for members whose benefits include infertility services; applies to both female and male reproductive system services under Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyAssisted Reproductive Technology

Policy CodePolicy CP.MP.55

Change TypeMaterial updates: added IVF/Conversion/FET criteriaclarified male specialist requirementCPT table cleanup

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed ART services and submit documentation demonstrating prior failed cycles or required clinical criteria.

SourceLink

POLICY UPDATE CHANGES

Under basic criteria, clarified that men were to be treated by board-certified urologist.

Added IVF, Conversion from IUI to IVF and FET criteria.

CPT code table updated and CPT code 89253 removed from table of CPT Codes that Support Medical Necessity.

12+Distinct ART procedures

30+CPT codes requiring PA

1 yr / 6 mo / immediateInfertility timing thresholds

≤ 90 daysCryopreservation beyond year

MultipleRevision entries

Coverage Criteria for Assisted Reproductive Technology (ART)

Basic criteria (all must be met)

Covered when ALL of the following are met:

Basic ART eligibility: 1. No untreatable anatomic cause of infertility and modifiable causes of infertility have been considered and addressed if possible; 2. Documentation of inability to conceive during 12 months of cycles exposed to sperm (including IUI), or 6 months for those with female reproductive systems ≥ age 35; 3. For those with female reproductive systems ≥ age 40 attempting conception using their own oocytes, documentation that the treating provider has evaluated age, infertility risk factors, measures of ovarian reserve, prior treatment and response, and considers use of the member/enrollee's own oocytes a viable strategy; 4. Infertility is unrelated to voluntary sterilization or failed reversal of voluntary sterilization of either partner; 5. Men with male reproductive system issues are evaluated/treated by a board-certified urologist as indicated.

Artificial Insemination (IUI/ICI) criteria

Covered when ALL of the following are met:

IUI/ICI criteria: a. Demonstrated unilateral or bilateral tubal patency; and b. One or more of the following indications: mild male factor infertility; cervical factors (e.g., stenosis, chronic cervicitis); ovulatory dysfunction treated with medications (e.g., clomiphene); unexplained infertility; sperm antibodies; endometriosis; utilization of cryopreserved sperm obtained for fertility preservation prior to gonadotoxic therapy; or special circumstances that obviate the standard timed exposure requirement (e.g., inability to have intercourse due to physical disability or psychosexual problem; HIV-positive male with available protocols; retrograde ejaculation with sperm washing; single females using donor sperm).

Policy Summary

PayerCentene

PolicyAssisted Reproductive Technology

Policy CodePolicy CP.MP.55

Change TypeMaterial updates: added IVF/Conversion/FET criteriaclarified male specialist requirementCPT table cleanup

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed ART services and submit documentation demonstrating prior failed cycles or required clinical criteria.

SourceLink

On This Page

Documentation should support the clinical indication and tubal status.

In Vitro Fertilization with Embryo Transfer (IVF-ET) criteria

Covered when ANY one of the following groups is met:

IVF-ET indications - group A: Barrier to fertilization: bilateral fallopian tube absence or obstruction not due to voluntary sterilization; endometriosis-associated infertility that failed endometriosis treatment interventions; severe male reproductive system infertility that has failed conservative treatments (sperm concentration <10 million/mL and/or normal morphology ≤1% by Kruger or ≤5% by WHO); prior IVF cycle with failed or poor fertilization of eggs.

See Table 1 for embryo transfer guidance.

IVF-ET indications - group B: Unexplained infertility after failure of at least three cycles of IUI with oral agents (e.g., clomiphene or letrozole).

IVF-ET indications - group C: High response to a medicated IUI cycle when the cycle meets BOTH: estradiol > 1000 pg/mL AND production of at least three follicles ≥16 mm or four to eight follicles >14 mm, and the cycle will be converted to IVF.Estradiol > 1000 pg/mL; follicles ≥16 mm (≥3) or 4–8 follicles >14 mm

Conversion to IVF required for high-response cycles.

IVF-ET indications - group D: Utilization of cryopreserved sperm and/or oocyte(s)/embryo(s) obtained for fertility preservation prior to non-elective medical or surgical treatment likely to cause infertility.

IVF-ET indications - group E: Inadequate number of frozen embryos available for transfer from a prior IVF cycle: fewer than 3 for those with a female reproductive system age <35 years, or fewer than 4 for those with a female reproductive system age ≥35 years.

Refer to Table 1 for embryo transfer limits.

Frozen Embryo Transfer (FET) criteria

Covered when ALL of the following are met:

FET criteria: a. Number of embryos to transfer per attempt meets the requirements in Table 1 (ASRM-based embryo transfer limits); and b. Frozen embryos must be used prior to authorization of additional IVF cycles in the following circumstances: i) those <35 years with at least 3 embryos available for transfer; ii) those ≥35 years with at least 4 embryos available for transfer; or iii) utilization of cryopreserved embryos obtained for fertility preservation prior to gonadotoxic treatment.

If the member continues with a diagnosis of infertility, FET with fewer embryos may still be considered medically necessary per policy note.

GIFT/ZIFT criteria

Covered when ALL of the following are met:

GIFT/ZIFT criteria: a. At least one patent fallopian tube; b. One of the following: utilization of cryopreserved gametes/embryos obtained for fertility preservation prior to gonadotoxic treatment, or unexplained infertility with failure of specified IUI cycles (for female reproductive system <38 years: failure of 3 IUI cycles with oral agents; for age 38–42: failure of at least 1 IUI cycle with oral agents); c. Clinical justification that GIFT/ZIFT is preferable to standard IVF for the member.

Documentation must justify preference for GIFT/ZIFT over IVF.

ICSI criteria

Covered when ANY one of the following is met:

ICSI indications: a. Fewer than two million motile spermatozoa per ejaculate; b. Anti-sperm antibodies contributing to infertility; c. Prior or repeated fertilization failure with standard IVF protocols (<50% fertilization); d. Washed sperm limited in number/quality; e. Male tract obstruction not amenable to repair necessitating MESA/TESE; f. Abnormal morphology (≤1% normal forms by Kruger; ≤5% by WHO); g. Specific spermatozoan defects impairing sperm-oocyte interaction; h. Fertilization of previously frozen oocytes or oocytes that have undergone in vitro maturation; i. Utilization of cryopreserved sperm and/or oocytes obtained for fertility preservation; j. HIV or hepatitis-discordant couples; k. Need for PGT-M in settings requiring absence of extraneous DNA contamination; l. Treatment of selected oocyte/zona anomalies.

Does not include obstruction due to voluntary sterilization.

Donor egg and donor sperm criteria

Covered when ANY one of the following is met:

Donor egg indications: Donor egg cycles covered for members with a female reproductive system who meet one of the following: congenital or surgical absence of ovaries; primary ovarian insufficiency (menopause before age 40); diminished ovarian reserve; ovarian failure after radiation or chemotherapy; previously failed IVF in those >40 years; gonadal dysgenesis (e.g., Turner syndrome); high risk of transmitting a genetic disorder; hypergonadotropic hypogonadism.

Donor sperm indications: Donor sperm covered for indications including partner with male reproductive system having bilateral congenital absence of the vas deferens (BCAVD); ejaculatory dysfunction; obstructive azoospermia; severe oligozoospermia or other significant semen abnormalities; single females; high infectious or genetic transmission risk from partner; partner post-radiation/chemotherapy with abnormal semen; non-obstructive azoospermia confirmed via MESA/TESE; two abnormal semen analyses at least 30 days apart; or failure of at least three cycles of IVF or ICSI when indicated.

Does not cover donor services when partner is not a member unless mandated by benefits.

TESE / sperm extraction

TESE indications: TESE, micro-TESE and epididymal sperm extraction are covered for male reproductive system members with obstructive or non-obstructive azoospermia.

Evaluation and documentation of azoospermia and prior attempts/diagnosis required.

Cryopreservation criteria

Cryopreservation of sperm: Short-term storage during the initial year is covered for members in active infertility treatment who underwent approved MESA or TESE; beyond the initial year, storage may be approved in increments up to 90 days at a time after the last approved infertility treatment.Initial year; beyond initial year up to 90 days at a time

Documentation of ongoing fertility treatment or need for storage required.

Cryopreservation of mature oocytes: Short-term storage of mature oocytes during the initial year is covered for members in active infertility treatment; beyond the initial year, storage may be approved in increments up to 90 days at a time after the last approved infertility treatment.Initial year; beyond initial year up to 90 days at a time

Refer to policy for programmatic details and limits.

General coverage criteria updates and additions

Coverage is provided when policy-specific criteria for ART procedures are met; the document includes multiple indexed criteria (e.g., I.A, I.B, II.F-II.H) governing indications and limits.

High-level policy updates: Policy updated with clarifications and additions including specification that men be evaluated/treated by board-certified urologists in basic criteria; addition and restructuring of IVF, conversion from IUI to IVF, and FET criteria; removal or revision of certain prior criteria (e.g., assisted hatching, selected cryopreservation language); and updates to age- and embryo-based transfer guidance. Specific numbered criteria (I.A, I.B, II) in the full policy contain the detailed logic and limits.

Refer to the full policy sections and Table 1 for embryo transfer limits and complete indexed criteria.

The policy explicitly identifies several categories that are considered not medically necessary or excluded from coverage, including any experimental infertility procedure, surrogacy, and reversal of voluntary sterilization. Additionally, commercially available over-the-counter home test kits (for ovulation or pregnancy) are excluded from coverage. These exclusions are described in the policy's NMN/exclusions listing and apply unless otherwise specified in a member's benefit documents.

The document notes that prior wording and some test- or technique-specific criteria have been removed or revised during updates. Examples include removal of assisted hatching criteria and edits to cryopreservation and certain laboratory-test thresholds; revisions were made to reformat and clarify criteria consistent with other Centene clinical policies.

Coverage under this clinical policy is subject to the terms, conditions, exclusions, and limitations of the member's coverage documents (e.g., Evidence of Coverage, certificate of coverage, policy or contract). State and federal requirements and Health Plan-level administrative policies may further govern coverage; when state Medicaid provisions conflict with this policy, state Medicaid rules take precedence.

The policy reiterates categories considered not medically necessary, including experimental infertility procedures, surrogacy, reversal of voluntary sterilization, and over-the-counter home test kits. It also lists additional NMN items such as infertility treatment following voluntary sterilization or unsuccessful reversal, partner infertility services for non-members (unless benefits mandate), and age-related exclusions (e.g., females >55 years).

During revision, the policy removed a prior phrasing that had stated an experimental infertility procedure would be excluded 'until the procedure becomes recognized as non-experimental.' The updated text omits that temporal phrasing and instead handles experimental procedures within the exclusions and criteria framework.

This clinical policy is intended as a guide to medical necessity and does not constitute medical advice. Providers are expected to exercise their professional medical judgment in diagnosing and treating members; the policy is not a substitute for individualized clinical decision-making and does not dictate the care a provider should deliver.

Coding and Code Lists

Infertility CPT Codes Requiring Prior AuthorizationCPTCovered

58321	Artificial insemination; intra-cervical
58322	Artificial insemination; intra-uterine
58323	Sperm washing for artificial insemination
58970	Follicle puncture for oocyte retrieval, any method
58974	Embryo transfer, intrauterine
58976	Gamete, zygote, or embryo intrafallopian tube transfer; any method
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)
89254	Oocyte identification from follicular fluid
89255	Preparation of embryo for transfer (any method)

1–10 of 26

1/3

HCPCS ART Case-Rate CodesHCPCS

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
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
S4017	Incomplete cycle, treatment canceled prior to stimulation, case rate
S4018	Frozen embryo transfer procedure canceled before transfer, case rate
S4020	In vitro fertilization procedure canceled before aspiration, case rate
S4021	In vitro fertilization procedure canceled after aspiration, case rate
S4022	Assisted oocyte fertilization, case rate

1–10 of 16

1/2

High response to IUI medicated cycle — clinical thresholds (estradiol and follicle counts)

Estradiol thresholdEstradiol level > 1000 pg/ml

Follicle count — larger folliclesProduction of at least 3 follicles ≥16 mm

Follicle count — broader rangeProduction of 4–8 follicles >14 mm in diameter

ICSI indication - semen threshold (< 2 million motile sperm per ejaculate)

ICSI semen indicationFewer than 2 million motile spermatozoa per ejaculate

Other ICSI indications (summary)Anti-sperm antibodies contributing to infertility; prior/repeated fertilization failure with standard IVF (<50% fertilization)

Cryopreserved gametes indicationUse of cryopreserved sperm and/or oocytes obtained for fertility preservation prior to gonadotoxic treatment

Severe male infertility - sperm concentration thresholds (<10 million/mL, morphology thresholds)

Severe male infertility — concentrationSperm concentration < 10 million/mL

Severe male infertility — morphology (Krüger)Normal morphology ≤1% by Krüger criteria

Severe male infertility — morphology (WHO)Normal morphology ≤5% by WHO criteria

Short-term cryopreservation duration — initial year, extensions up to 90 days

Initial short-term storage periodShort-term storage during the initial year for members in active infertility treatment

Extensions after initial yearBeyond the initial year, extensions up to 90 days approved at a time after last approved infertility treatment

Applicable to gametesApplies to cryopreservation of sperm and mature oocytes as described in criteria

Age limits mentioned in criteria (≤54, >55 handling)

Age consideration — primary bandThose with a female reproductive system who are ≤ 54 years of age referenced under criteria II.G

Age handling — older than 55Those with a female reproductive system > 55 years of age are specifically addressed in criteria II.H

Menopause exceptionMenopausal members ≤54 may be considered when using donor egg for premature diminished ovarian reserve or premature ovarian failure

Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Assisted Reproductive Technology (ART) services when such services are a covered benefit under the member's plan. Prior authorization must be obtained before performing listed infertility procedures to confirm medical necessity and benefit eligibility.

Prior authorization required for listed CPT and HCPCS/HCPCS-like case rate codes when covered by the benefit plan (see code groups).
Authorization is subject to the member's specific benefit contract — services are covered only when the member's benefit plan provides coverage.
For Medicaid members/enrollees, state Medicaid coverage provisions take precedence over this policy when conflicts exist.

Documentation Required

Required Clinical Documentation and IVF/FET Supporting Data

Providers must submit clinical documentation to support medical necessity at the time of prior authorization and with claims. Documentation should demonstrate that basic and treatment-specific criteria in the policy are met, and should include the clinical data listed below.

History and duration of infertility (documentation of inability to conceive: 12 months of cycles exposed to sperm, or 6 months if the person with a female reproductive system is ≥35).
Evaluation of causes of infertility and evidence that modifiable causes have been considered and addressed where possible (e.g., anatomic causes, reversible factors).
Provider assessment for patients ≥40 using own oocytes, including ovarian reserve testing and prior treatment/response.
For IVF/FET: documentation of prior failed cycles (e.g., number and outcomes of IUI/IVF attempts), ovarian stimulation response (estradiol levels, follicle counts), number of embryos available/frozen, and reason for conversion from IUI to IVF when applicable.

Step Therapy

Conservative Therapy Prerequisites and Therapy Escalation Guidance (IUI → IVF → FET)

Conservative therapy prerequisites and escalation pathway should be documented. In general, less invasive therapies should be attempted and documented prior to escalation to IVF unless specific indications permit earlier escalation.

IUI (artificial insemination) should be used for indicated conditions (e.g., ovulatory dysfunction treated with medications, mild male factor, cervical factors, unexplained infertility) with documentation of tubal patency when required.
IVF is indicated after failure of conservative treatments or when specific indications exist (e.g., bilateral tubal absence/obstruction, severe male factor infertility, prior failed fertilization, or unexplained infertility after at least three cycles of IUI with oral agents).
High-response IUI cycles that meet estradiol and follicle criteria (e.g., estradiol >1000 pg/mL and ≥3 follicles ≥16 mm or 4–8 follicles >14 mm) should be converted to IVF; document estradiol and follicle measurements.
FET must follow the policy's embryo-availability rules (e.g., use frozen embryos prior to authorization of additional IVF cycles; thresholds described by age: <35 with ≥3 embryos, ≥35 with ≥4 embryos) unless medically justified otherwise.

Billing Rule

Coding, Documentation Guidance, and Claim Submission

Coding and claim submission must follow current professional coding guidance. CPT, HCPCS and other codes included in this policy are informational and do not guarantee coverage; providers should verify up-to-date code sets and submit supporting clinical documentation with prior authorization requests and claims.

Reference current CPT guidance and the most up-to-date code manuals prior to claim submission.
Include the clinical rationale and all supporting documentation with the prior authorization request for listed codes (e.g., 58321, 58322, 58970, 58974, 89250–89291, 89337, 89352–89356 and applicable S-codes such as S4011–S4037).
Inclusion or exclusion of a code in the policy is informational; check the member's coverage documents for benefit limitations and contract-specific rules.
Follow Health Plan-level billing instructions and applicable state/federal claim filing requirements.

Note

Coverage Conditions and State Precedence

Coverage decisions are made per the member's coverage documents and applicable state and federal requirements. This policy is effective as determined by the Health Plan and Health Plan-level administrative policies and procedures apply.

Coverage is subject to the terms, conditions, exclusions and limitations of the member's evidence of coverage, certificate of coverage, policy or contract.
The Health Plan may have additional administrative policies and procedures that affect authorization and coverage.
If state Medicaid provisions conflict with this policy, state Medicaid rules take precedence; consult the state Medicaid manual for specific provisions.

Definitions and Key Terms

Infertility — timing thresholds by age for those with a female reproductive system

Infertility — <35 yearsFailure to achieve pregnancy after 1 year of exposure to sperm

Infertility — ≥35 yearsFailure to achieve pregnancy after 6 months of exposure to sperm

Infertility — ≥40 yearsMay be considered more immediately (immediate consideration at age 40 and over)

IVF-ET / ICSI definitions — laboratory fertilization and microinjection description

IVF-ET definitionFertilization of an egg with sperm outside the body in a laboratory with resulting embryo placed into the uterus (embryo transfer)

ICSI brief descriptionInjection/microinjection of a single sperm into an oocyte in the laboratory to achieve fertilization; embryos transferred or cryopreserved

IVF-ET cycle componentsIncludes ovulation stimulation and monitoring, oocyte retrieval, sperm preparation, fertilization/incubation, and embryo transfer

ZIFT definition — placement of zygotes/embryos into fallopian tube

ZIFT definitionPlacement of fertilized eggs (zygotes) or embryos into the fallopian tube via laparoscopy

Clinical contextAnalogous to GIFT; may be used when trans-cervical transfer is difficult or uterine abnormalities are present

Procedure noteLaparoscopy is required to place zygotes in the fallopian tubes

ICSI definition — microinjection of single sperm into oocyte

ICSI definitionLaboratory microinjection of a single sperm into an oocyte to achieve fertilization

Indications referencedIndicated for prior failed fertilization or when sperm concentration/motility are too low for conventional IVF

Post-procedure stepsEmbryos are transferred to the uterus or cryopreserved for future FET

Infertility definitions referenced from ASRM committee opinion

ASRM definitions referencedPractice Committee of the American Society for Reproductive Medicine: Definitions of infertility and recurrent pregnancy loss (Fertil Steril. 2020)

Ethics guidance referencedASRM Ethics Committee opinion on oocyte or embryo donation to women of advanced reproductive age (Fertil Steril. 2016)

PGT-M guidance referencedASRM guidance on use of preimplantation genetic testing for monogenic defects (PGT-M) and related ethics opinions

Background on Assisted Reproductive Technologies

Assisted reproductive technologies (ART) encompass both laboratory and clinical procedures that handle oocytes, sperm, or embryos to establish pregnancy. Typical ART workflow includes stimulation of the ovaries, oocyte retrieval, laboratory fertilization (including IVF-ET and laboratory techniques such as ICSI), embryo culture and possible genetic testing, and embryo transfer. This policy addresses the medical necessity criteria and coverage considerations for these procedures for members whose benefits include infertility services.