CurrentCentenePolicy HNCA CP MP.130

Clinical Policy: Fertility Preservation

Defines medical necessity criteria for fertility preservation procedures for members/enrollees facing medically necessary treatments likely to cause infertility, including ovarian stimulation and oocyte retrieval, ovarian tissue retrieval, ovarian transposition, and sperm extraction/retrieval; lists procedures considered insufficient evidence/experimental (e.g., ovarian/testicular suppression, reimplantation of testicular tissue). References cryopreservation guidance in separate policy CP.MP.55.

Policy Summary

PayerCentene

PolicyClinical Policy: Fertility Preservation

Policy CodePolicy HNCA CP MP.130

Change TypeNon-material annual review / historical coding edits

Effective DateJul 1, 2025

Next Review Date

Key ActionEnsure fertility preservation procedures are performed prior to commencing medically necessary treatments likely to cause infertility and document required evaluations (e.g., age 40 oocyte retrieval assessment; ovarian tissue free of malignancy).

SourceLink

POLICY UPDATE CHANGES

Policy adopted from Health Net NMPS12 and expanded criteria to include iatrogenic causes of infertility; added ICD-10 codes D27.0, D27.1, N70.03 (prior revision history).

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Coverage Summary

Defines medical necessity criteria for fertility preservation procedures for members/enrollees facing medically necessary treatments likely to cause infertility, including ovarian stimulation and oocyte retrieval, ovarian tissue retrieval, ovarian transposition (oophoropexy), and sperm extraction/retrieval; also lists procedures considered insufficient evidence/unsupported (for example, ovarian/testicular suppression with GnRH agonists/antagonists and reimplantation or grafting of human testicular tissue).

Effective date: 2025-07-01. Last review: 2025-07-01.

Display thresholds and quick facts - Fertility preservation

Age threshold for oocyte retrieval counselingAge 40 (for members/enrollees age 40 requesting retrieval of their own oocytes, provider must document evaluation of age, infertility risk factors, ovarian reserve, and viability of using own oocytes)

Primary covered procedures (female/male)4

Procedures listed as insufficient evidence3

Referenced CPT/HCPCS/lab codes listed~30

Medically Necessary — Individuals with Female Reproductive System

Medically Necessary - Individuals with female reproductive system

Covered when ALL of the following are met:

ALL of the following

Member/enrollee is an adult or adolescent with a female reproductive system who is scheduled to commence a medically necessary treatment that is likely to cause infertility (excluding voluntary sterilization).
One of the following fertility preservation procedures is planned: ovarian stimulation and retrieval of oocytes; ovarian tissue retrieval with cryopreservation; or ovarian transposition (oophoropexy).
Ovarian tissue retrieval specific
- Ovarian tissue is free from malignancy.
  Operational note: tissue must be evaluated to exclude malignancy prior to retrieval for cryopreservation or transplantation.

Not Supported / Insufficient Evidence — Individuals with Female Reproductive System

Not supported / Insufficient evidence - Individuals with female reproductive system

The following procedures are considered to have insufficient evidence and are not supported for fertility preservation:

ANY of the following

GnRH suppression: Ovarian suppression with gonadotropin releasing hormone (GnRH) agonist or antagonists.
Listed as insufficient evidence / controversial

Denial Risk

Insufficient evidence: ovarian suppression with GnRH agents

The policy states there is insufficient evidence to support ovarian suppression with GnRH agonists or antagonists for fertility preservation. Guideline summaries note the use of GnRH analogs for ovarian protection remains controversial and evidence is inconclusive; ASCO and NCCN also indicate insufficient evidence that GnRH suppression adequately preserves fertility.

Medically Necessary — Individuals with Male Reproductive System

Medically Necessary - Individuals with male reproductive system

Covered when ALL of the following are met:

ALL of the following

Covered procedures: Procedure is sperm extraction and retrieval procedures.
Timing relative to gonadotoxic treatment: Procedure is to be performed prior to commencing medically necessary treatment that is likely to cause infertility (excluding voluntary sterilization).
Requirement: performed prior to gonadotoxic treatment

Prior Authorization

Prior to gonadotoxic treatment

Not Supported / Insufficient Evidence — Individuals with Male Reproductive System

Not supported / Insufficient evidence - Individuals with male reproductive system

The following procedures are considered to have insufficient evidence and are not supported for fertility preservation:

ANY of the following

Testicular tissue reimplantation/grafting: Reimplantation or grafting of human testicular tissue.
Listed as experimental/insufficient evidence
Testicular suppression with GnRH agonist or antagonists.
Listed as ineffective / insufficient evidence

Denial Risk

Insufficient evidence: testicular tissue reimplantation and hormonal suppression

The policy identifies reimplantation/grafting of human testicular tissue and testicular suppression with GnRH agonists/antagonists as having insufficient evidence and not supported for fertility preservation.

Coding

Referenced CPT / HCPCS / Laboratory / Procedure codes (informational; inclusion does not guarantee coverage)mixed

00840	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified.
00922	Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles.
53899	Unlisted procedure, urinary system.
55870	Electroejaculation.
55899	Unlisted procedure, male genital system.
58825	Transposition, ovary(s).
58970
76856	Ultrasound, pelvic (nonobstetric) real time with image documentation; complete.
76948	Ultrasonic guidance for aspiration of ova; imaging supervision and interpretation.
82670	Estradiol; total.

1–10 of 32

1/4

CPT Codes that do not support medical necessityCPTNot Covered

53899	Unlisted procedure, urinary system.
55899	Unlisted procedure, male genital system.
89398	Unlisted reproductive medicine laboratory procedure.

Codes listed in this policy are provided for informational purposes only; inclusion or exclusion of codes does not guarantee coverage. See policy number HNCA CP MP.130 for clinical criteria and the policy effective date 2025-07-01 when determining coverage.

Background & Evidence Summary

Fertility can be transiently or permanently affected by gonadotoxic treatments such as chemotherapy, radiation, and surgical resection, as well as other iatrogenic causes; rates of infertility depend on factors including treatment type, dose, patient age, and pretreatment fertility. Prompt counseling about fertility preservation options should be provided before initiating any gonadotoxic therapy.

Major specialty societies inform the guidance summarized in this policy: ASRM (2019) indicates that ovarian tissue cryopreservation is no longer considered experimental for prepubertal girls and those who cannot delay stimulation, while noting limited data; ASCO emphasizes that sperm cryopreservation is the only established method for males and that hormonal therapies have not demonstrated effectiveness; NCCN recommends oocyte/embryo cryopreservation if therapy can be delayed about three weeks and recognizes ovarian tissue cryopreservation as a promising option when time is insufficient or for prepubertal patients; ACOG similarly notes that cryopreservation of oocytes or embryos may be offered when there is adequate time and that evidence for GnRH analogues is inconclusive.

ASRM 2019 committee opinion: Ovarian tissue cryopreservation no longer considered experimental for prepubertal girls and those who cannot delay stimulation; data limited.

ASCO: Sperm cryopreservation is the only established method for males; hormonal therapies not demonstrated effective.

NCCN: Oocyte/embryo cryopreservation recommended if can delay therapy ~3 weeks; ovarian tissue cryopreservation promising when insufficient time or prepubertal.

Definitions

Provider Actions & Documentation Requirements

Documentation Required

Ovarian tissue malignancy exclusion

Ovarian tissue retrieval requires documentation that the ovarian tissue is free from malignancy. Indication includes insufficient time for oocyte retrieval or prepubertal status.

Required documentation: ovarian tissue free from malignancy
Indications: insufficient time for oocyte retrieval; prepubertal patients
Affected procedures: ovarian tissue retrieval; ovarian transposition

Providers should reference the separate cryopreservation policy CP.MP.55 for technical coverage details related to cryopreservation procedures and related services.

Revision History

revised

Policy adopted from Health Net NMPS12 and expanded criteria to include iatrogenic causes of infertility; added ICD-10 codes D27.0, D27.1, N70.03; multiple historical edits adding and removing CPT/HCPCS codes and clarifying criteria; most recent listed annual reviews through 01/25 with no clinical criteria changes noted.

2025-07-01effectiveLatest

Policy effective date.

2025-07-01effective