CurrentCentenePolicy CP MP.55

Assisted Reproductive Technology (ART)

Defines medical necessity, covered procedures, and criteria for assisted reproductive technologies for members whose benefit plans include infertility services; applies to both female and male reproductive system indications.

Policy Summary

PayerCentene

PolicyAssisted Reproductive Technology (ART)

Policy CodePolicy CP MP.55

Change TypeNo material change indicated

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit required clinical documentation (including fertility timeline, diagnostic evaluations, and relevant CPT/HCPCS codes) when infertility services are a covered benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10+ART procedures enumerated

12Treatment-specific sections

ListedNot medically necessary items

89253CPT code removed

ICSIICSI noted

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Basic Criteria

Covered when ALL of the following basic criteria are met:

Basic Criteria: 1) ART is performed by a physician board-certified or board-eligible in reproductive endocrinology for those with a female reproductive system and by a board-certified or board-eligible urologist or reproductive endocrinologist for those with a male reproductive system.

Basic Criteria: 2) There is no untreatable anatomic cause of infertility and modifiable causes of infertility have been considered and modified when possible.

Basic Criteria: 3) Documentation of inability to conceive: at least 12 months of exposure to sperm (including IUI) for those under age 35, or at least 6 months for those age 35 or older.

Basic Criteria: 4) For members with a female reproductive system age 40 or older attempting conception with their own oocytes, documentation that the treating provider has evaluated age, infertility risk factors, ovarian reserve, prior treatment and response, and strategy for attempting conception.

Basic Criteria: 5) Infertility is not related to voluntary sterilization or failed reversal of voluntary sterilization of either partner unless specific supporting evidence is provided (e.g., for vasectomy reversal, two recent normal semen analyses within the past three months per specified parameters; for tubal reanastomosis, documentation of tubal patency by hysterosalpingogram).

Treatment-Specific Criteria

Treatment-specific criteria: ART is medically necessary when basic criteria are met AND one of the following treatment-specific indications applies.

Artificial Insemination (ICI/IUI): Requires unilateral or bilateral tubal patency and at least one of: mild male factor infertility; unexplained infertility; cervical factors; sperm antibodies; utilization of cryopreserved sperm obtained for fertility preservation before gonadotoxic treatment; endometriosis; inability or extreme difficulty with vaginal intercourse due to physical disability or psychosexual problem; HIV-positive male undergoing sperm washing; member with a female reproductive system using donor sperm.

Certain indications (e.g., donor sperm use, sperm washing for HIV) may not require demonstration of infertility timeframe per policy revisions.

In Vitro Fertilization with Embryo Transfer (IVF-ET): Indications include barriers to fertilization such as bilateral fallopian tube absence or obstruction (not due to voluntary sterilization); severe male factor infertility failing conservative treatments (sperm concentration ≤10 million/mL and/or morphology criteria such as <1% Kruger/<5% WHO); endometriosis-associated infertility failing treatment; prior IVF with failed or poor fertilization; unexplained infertility after failed IUI cycles; conversion from medicated IUI cycles when response necessitates IVF; and use of cryopreserved gametes/embryos for fertility preservation prior to gonadotoxic therapy.

Policy notes embryo-availability guidance (Table 1): e.g., guidance on number of frozen embryos available for transfer by age groups.

Selected Indications and Administrative Criteria

Selected coverage guidance and administrative criteria:

ICSI indications: ICSI should be available to patients with previously failed fertilization and to patients with spermatozoa concentration and motility too low to expect success with conventional IVF; patients should be counseled regarding outcomes and the (small) potential neonatal risks.

Prior authorization requirement: Infertility services require prior authorization if they are a covered benefit; providers must submit supporting CPT and HCPCS codes listed in the policy to support medical necessity determinations.

Code lists and prior-authorization guidance are provided in the policy excerpt.

PGT-M (preimplantation genetic testing for monogenic disorders): PGT-M may be necessary when absence of extraneous DNA contamination from other sperm is required (e.g., carriers of cystic fibrosis, BRCA mutations, congenital adrenal hyperplasia); this need is explicitly added to the policy.

The policy explicitly lists certain services that are not medically necessary. These include surrogacy, experimental infertility procedures, and reversal of voluntary sterilization. Also excluded are infertility treatment that is required as a result of prior voluntary sterilization or unsuccessful sterilization reversal, commercially available over-the-counter home test kits (for example, ovulation prediction and pregnancy test kits), and a partner's infertility services when the partner is not a covered member/enrollee unless mandated by benefits.

The policy revision notes that CPT code 89253 was removed from the table of CPT Codes that Support Medical Necessity. In addition, the revision states that ICD-10 codes were removed from the policy.

Coverage determinations made under this clinical policy are guidance for medical necessity only. Actual coverage and benefit administration remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract of insurance), and to applicable state and federal requirements and Health Plan administrative policies.

Examples of items considered not medically necessary include reversal of voluntary sterilization, surrogacy, and experimental procedures. The policy also specifies that commercial over-the-counter home test kits are not covered, and that infertility services for a partner who is not a covered member/enrollee are not covered unless required by benefit terms.

The document records updates to policy language and removal of certain items: it specifies removal of selected outdated criteria and states that CPT code 89253 was deleted from the CPT table; it also indicates that ICD-10 codes were removed. In addition, the revision log documents edits to experimental-procedure statements and other exclusion wording to reflect the current criteria.

Coding and Definitions

Referenced coding guidancemixed

No codes listed

CPT Codes that Support Medical Necessity (partial list)CPT

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
58976
89250	Culture of oocyte(s)/embryo(s) less than 4 days.
89251	Culture of oocyte(s)/embryo(s), less than 4 with co-culture of oocyte(s)/embryo(s).
89254	Oocyte identification from follicular fluid.

CPT Codes that Support Medical Necessity (continued)CPT

89255	Preparation of embryo for transfer (any method).
89257	Sperm identification from aspiration (other than seminal fluid).
89258	Cryopreservation; embryo(s).
89259	Cryopreservation; sperm.
89260	Sperm isolation; simple prep (e.g., sperm diagnosis/with semen analysis/wash).
89261	Sperm isolation; complex prep (e.g., Percoll gradient; albumin gradient).
89264	Sperm identification from testis tissue, fresh or cryopreserved.
89268	Insemination of oocytes.
89272	Extended culture of oocyte(s)/embryo(s) 4-7 days.
89280

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HCPCS 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
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

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Time to define infertility — policy thresholds

DefinitionInfertility is inability to conceive after 12 months of sperm exposure for those under 35 years of age, or after 6 months for those aged 35 years or older.

Evidence requiredDocumentation must demonstrate duration of inability to conceive per age-based thresholds (12 months if <35; 6 months if ≥35).

ApplicabilityThis definition applies to members whose benefit plan includes infertility services; coverage is subject to plan terms and conditions.

IVF embryo availability threshold (authorization guidance)

IVF embryo availability thresholdAuthorization guidance: for patients <35 years old, at least three embryos available for transfer; for patients ≥35 years old, at least four embryos available for transfer.

Use for FET authorizationFrozen embryos may be used to authorize additional IVF cycles when prior criteria are met; if member continues to qualify for infertility, FET with fewer embryos may be considered medically necessary.

Reference guidanceEmbryo-number guidance references ASRM limits (see Table 1) and is used to determine number of embryos to transfer per attempt.

Age limits and changes — policy indicates multiple age-related criteria changes

Policy revision noteThe policy text indicates multiple age-related criteria changes across revisions (examples include adjusted IVF age cutoffs such as changes around ages 38–42).

Age-specific IVF criteriaCertain treatment-specific criteria reference age bands (e.g., failure of specified IUI cycles for age 38 or age 38–42), indicating age-dependent thresholds for treatment eligibility.

Coverage applicabilityAge-based criteria affect medical necessity determinations and authorization decisions; providers should confirm current age thresholds in the policy when submitting requests.

Provider Actions, Authorization & Documentation

Note

Coverage & Provider Obligations

Authorization is required when infertility/ART services are a covered benefit under the member's benefit plan. Coverage is governed by the member/enrollee's specific benefit documents; services are covered only when infertility services are included in the member's plan and all policy criteria are met.

Coverage is subject to the terms, conditions, exclusions and limitations of the member's benefit plan (e.g., EOC, certificate of coverage, policy).
Medicaid and Medicare rules (NCDs/LCDs) take precedence where applicable.
Providers submitting claims or providing services are bound by the terms and conditions of this clinical policy and applicable contract provisions.

Prior Authorization

Prior Authorization Guidance

Prior authorization is required for infertility/ART services when the member's benefit plan covers these services. Prior authorization decisions follow the Health Plan's authorization procedures and are guided by the medical necessity criteria in this clinical policy.

Prior authorization must document how the member meets the basic and treatment‑specific criteria in the policy.
Authorization requests will be reviewed against the policy's medical necessity criteria and the member's benefit limitations.
The date of posting of this clinical policy may not be the effective date used by the Health Plan; follow plan-level authorization procedures.

Prior Authorization

Infertility Services Requiring Prior Authorization if Covered

Certain infertility services require prior authorization if they are a covered benefit. Providers should obtain prior authorization before performing these services to avoid claim denials when coverage applies.

Examples of CPT codes that commonly require prior authorization when covered: 58321, 58322, 58323, 58970, 58974, 58976, 89250–89258, 89264, 89268, 89272, 89280–89291, 89337, 89352–89356.
Examples of HCPCS/S codes that commonly require prior authorization when covered: S4011, S4013–S4018, S4020–S4023, S4025–S4028, S4035, S4037.
The lists above are illustrative; providers must reference the plan's prior authorization tools for the definitive list and submission instructions.

Billing Rule

Coding Inclusion Is Not a Guarantee of Coverage

Inclusion of codes in this policy is informational and does not guarantee coverage. Providers must verify benefit coverage and current coding guidance prior to claim submission.

Always reference the most up-to-date professional coding resources and the member's benefit plan.
Billing with outdated or non-covered codes may result in denials or claim adjustments.

Documentation Required

Prior Authorization — Required Supporting Documentation & Codes

Prior authorization requests must be supported by relevant clinical documentation and appropriate procedure codes to demonstrate medical necessity per the policy criteria.

Provide documentation that supports the Basic Criteria and Treatment‑Specific Criteria described in the policy (e.g., duration of infertility, evidence of prior treatments, diagnostic test results, ovarian reserve assessment, semen analyses, hysterosalpingogram results).
Include the specific CPT/HCPCS codes for the requested services and any associated diagnostic ICD-10 codes.
Supporting codes listed in the policy (CPT and HCPCS) are intended to be used to substantiate the services requested during prior authorization reviews.

Step Therapy

Prior Conservative Treatment & Treatment Sequencing Notes

Certain ART interventions require failure of less invasive/conservative treatments before authorization of more invasive procedures (when such sequencing is clinically appropriate and when covered by the plan).

For IVF consideration in unexplained infertility or ovulatory dysfunction, failure of prior cycles of IUI (with oral agents such as clomiphene or letrozole) or other conservative therapy is required as specified in the Treatment‑Specific Criteria.
Severe male factor infertility should have failed conservative treatments prior to advanced ART per policy thresholds (e.g., sperm concentration and morphology criteria).
Some indications (e.g., use of donor sperm for those without a partner, sperm washing for HIV-positive partners, or inability to have intercourse due to disability) may be exempt from the standard duration or conservative‑therapy requirements as noted in the policy.

Note

Treatment Sequencing Notes

Treatment sequencing is addressed in the policy criteria but the policy does not establish an explicit step‑therapy protocol beyond the specified conservative‑treatment requirements and clinical exceptions.

Policy criteria reference sequencing between IUI and IVF (including circumstances for conversion from IUI to IVF and criteria for frozen embryo transfers), and specify when prior IUI cycles or oral‑agent stimulation failures are required.
No additional plan-level step therapy beyond the policy's stated clinical sequencing requirements should be inferred; follow plan authorization rules for any operational sequencing requirements.

Key Definitions

Infertility definition (DEFINITIONS)

DefinitionInfertility: inability to conceive or produce conception during a period of one year for those under age 35, or during a period of six months for those aged 35 years or older.

ScopeDefinition applies to members with a female reproductive system for purposes of this policy when infertility services are a covered benefit.

Plan conditionDiagnostic infertility services and treatment are covered only when specifically provided under the member's benefit plan; coverage is subject to plan terms and conditions.

Assisted Reproductive Technologies (ART) — definition

DefinitionAssisted Reproductive Technologies (ART): clinical treatments and laboratory procedures involving handling of human oocytes, sperm, or embryos with the intent of establishing pregnancy (includes IVF, IUI, ICSI, GIFT, ZIFT, cryopreservation, etc.).

Components of IVFIVF includes ovarian stimulation and monitoring, oocyte retrieval, sperm preparation, in‑vitro fertilization, embryo culture, and embryo transfer (including frozen embryo transfer).

Policy useART procedures are considered medically necessary when performed solely for treatment of infertility and when ART criteria in the Policy/Criteria section are met.

Intra‑Cytoplasmic Sperm Injection (ICSI) — definition and indications

Definition/TechniqueIntra‑Cytoplasmic Sperm Injection (ICSI) involves injecting a single sperm directly into an oocyte in the laboratory to achieve fertilization; embryos are then transferred or cryopreserved for future transfer.

IndicationsICSI is indicated for previously failed fertilization with standard IVF, for severe semen abnormalities (e.g., very low motile sperm concentration or abnormal morphology), obstruction requiring MESA/TESE, washed sperm of limited number/quality, fertilization of previously frozen or in‑vitro matured oocytes, and specific sperm‑oocyte interaction defects.

Counseling pointPatients should be counseled about outcomes and potential, though small, neonatal risks associated with ICSI.

Health Plan — definition and applicability

DefinitionHealth Plan: a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or affiliated entities.

PurposeThe clinical policy provides guidance to assist in medical necessity determinations used for coverage decisions and administration of benefits, but does not constitute a contract or guarantee of payment.

GovernanceCoverage decisions and benefit administration remain subject to all terms, conditions, exclusions, and limitations of the member's coverage documents and applicable state/federal requirements.

OpenPayer

Assisted Reproductive Technology (ART)

Coverage Criteria and Indications

Coding and Definitions

Provider Actions, Authorization & Documentation

Background

Key Definitions