ModifiedCentenePolicy CP MP.130

Clinical Policy: Fertility Preservation

Defines medical necessity and investigational determinations for fertility preservation procedures for members/enrollees undergoing medically necessary treatments likely to cause infertility; applies to adolescents and adults with reproductive systems affected by such treatments.

Policy Summary

PayerCentene

PolicyClinical Policy: Fertility Preservation

Policy CodePolicy CP MP.130

Change TypeExpanded criteriacoding updatesgender-neutral language edits

Effective DateN/A

Next Review DateJan 25, 2025

Key ActionObtain and document required clinical information and perform specified fertility preservation procedures (e.g., ovarian stimulation and oocyte retrieval or sperm cryopreservation) prior to starting medically necessary gonadotoxic treatment when covered by the member's benefit contract.

SourceLink

POLICY UPDATE CHANGES

Expanded criteria to include iatrogenic causes of infertility and added ICD-10 codes D27.0, D27.1, N70.03.

Removed CPT 0375T (deleted 1/1/20) and multiple other CPT/HCPCS codes from the 'does not support' table and updated codes.

Replaced gendered language with gender-neutral verbiage throughout the policy.

3female procedure groups

2female procedures not established

1male established method

multiple

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Fertility Preservation

Female reproductive system - Medically necessary procedures

Covered when ALL of the following are met:

Female-system preservation - initial: Member/enrollee is an adult or adolescent with a female reproductive system who is about to commence medically necessary treatment that is likely to cause infertility (excluding voluntary sterilization).

Procedures considered medically necessary: One of: ovarian stimulation and retrieval of oocytes; ovarian tissue retrieval when ovarian tissue is free from malignancy and when there is insufficient time for oocyte retrieval or member is prepubertal; ovarian transposition (oophoropexy).

Note: For those age 40 requesting retrieval of their own oocytes, documentation is required noting that the treating provider has evaluated age, infertility risk factors, measure of ovarian reserve, and considers use of the procedure.

Female reproductive system - Insufficient evidence

Considered not established / insufficient evidence:

Female-system investigational/insufficient: Ovarian suppression with gonadotropin-releasing hormone (GnRH) agonists or antagonists for fertility preservation.

ASRM/ASCO/NCCN note evidence is controversial or insufficient; further studies required.

Male reproductive system - Medically necessary procedures

Covered when ALL of the following are met:

Male-system preservation - initial: Member/enrollee is an adult or adolescent with a male reproductive system who is about to commence medically necessary treatment that is likely to cause infertility (excluding voluntary sterilization).

Procedures considered medically necessary: Sperm extraction and retrieval procedures, including sperm cryopreservation where applicable.

ASCO notes sperm cryopreservation is the only established fertility preservation method for males.

Male reproductive system - Insufficient evidence

Considered investigational/insufficient evidence:

Male-system investigational: Reimplantation or grafting of human testicular tissue and testicular suppression with GnRH agonists or antagonists.

ASCO states these methods are experimental or have failed to demonstrate effectiveness.

Procedures identified in this policy as having insufficient evidence and therefore not supported as standard fertility preservation techniques include: ovarian suppression with gonadotropin-releasing hormone (GnRH) agonists or antagonists, and procedures such as reimplantation or grafting of testicular tissue (see exclusions and investigational sections). These determinations reflect that peer-reviewed evidence and professional guidance do not establish these methods as effective fertility preservation options for adults and adolescents with affected reproductive systems.

When no separate contract or plan-specific language exists, providers, members/enrollees and their representatives are expected to follow the terms of this clinical policy and the applicable benefit plan when services are provided or claims submitted. Coverage determinations remain subject to all plan terms, conditions, exclusions and limitations; where state Medicaid provisions or other legal/regulatory requirements conflict with this policy, the applicable law or state Medicaid manual takes precedence.

The policy explicitly identifies certain unlisted CPT codes that do not support medical necessity for fertility preservation services: 53899 (Unlisted procedure, urinary system), 55899 (Unlisted procedure, male genital system), and 89398 (Unlisted reproductive medicine laboratory procedure). Providers should note these specific code listings when submitting claims for fertility preservation services.

Coding and Billing

Referenced CPT/HCPCS/Lab codesmixed

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 23

1/3

CPT Codes that do not support medical necessity (as called out in document)CPTNot Covered

53899	Unlisted procedure,urinary system.
55899	Unlisted procedure,_male_genital system.
89398	Unlisted reproductive medicine laboratory_procedure.

Delay required for oocyte/embryo cryopreservation — approximately three weeks

Typical delay before oocyte/embryo cryopreservationApproximately three weeks (NCCN notes oocyte or embryo cryopreservation is recommended for those who can delay cancer therapy for approximately three weeks).

Context for delayDelay applies when ovarian stimulation and retrieval of oocytes or embryo cryopreservation is planned and the patient can safely postpone gonadotoxic therapy.

Alternative when delay not possibleOvarian tissue cryopreservation may be considered when there is insufficient time for oocyte or embryo cryopreservation or the patient is prepubertal.

Reference guidanceRecommendation based on NCCN Adolescent and Young Adult Oncology guidance regarding timing for cryopreservation prior to cancer therapy.

Provider Requirements and Actions

Prior Authorization

Regulatory checks before authorization

Prior authorization and regulatory review required before applying clinical criteria. Providers must review applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare Coverage Articles, and state Medicaid manuals (for Medicaid members) to ensure consistency with those rules prior to authorization requests.

Medicare: review all applicable NCDs, LCDs, and Medicare Coverage Articles before applying policy criteria; refer to CMS website.
Medicaid: state Medicaid coverage provisions take precedence where they conflict with this clinical policy; refer to the applicable state Medicaid manual.
Commercial/other plans: follow plan contract terms and Centene prior authorization processes.

Documentation Required

Age 40+ oocyte retrieval documentation

For members age 40 and older requesting retrieval of their own oocytes, the treating provider must document assessment of age, infertility risk factors, and a measure of ovarian reserve, and must state the clinical rationale for proceeding with oocyte retrieval given the age-related decline in fertility.

Background and Scope

Gonadotoxic treatments such as chemotherapy, radiation, and surgery can produce temporary or permanent infertility. Fertility preservation counseling should occur as early as possible, before the initiation of treatments likely to affect reproductive capacity. Options and recommended approaches depend on the patient’s reproductive system, age and developmental status, available time before treatment, and the risk of reintroducing malignant cells with tissue-based procedures; these considerations are used to determine medically necessary interventions and to identify procedures that remain investigational.

Definitions

Ovarian tissue cryopreservation — Removal and cryopreservation of ovarian tissue for future transplantation

DefinitionRemoval and cryopreservation of ovarian tissue for future transplantation; may be used when there is insufficient time for oocyte retrieval or the patient is prepubertal.

Evidence statusConsidered established for select prepubertal patients and for those who cannot delay treatment, but overall evidence on outcomes and safety remains limited.

When appropriateOffered to carefully selected patients; not appropriate for patients at risk of reintroducing malignant cells (e.g., certain cancers, BRCA carriers).

Stimulation requirementHormonal stimulation is not required for ovarian tissue cryopreservation; therefore it does not delay initiation of gonadotoxic therapy.

Sperm cryopreservation — Collection and freezing of sperm

Policy Summary

PayerCentene

PolicyClinical Policy: Fertility Preservation

Policy CodePolicy CP MP.130

Change TypeExpanded criteriacoding updatesgender-neutral language edits

Effective DateN/A

Next Review DateJan 25, 2025

SourceLink

On This Page

Documentation must note the provider's evaluation of: age-related fertility risk, relevant infertility risk factors, and objective ovarian reserve testing (for example, AMH level or antral follicle count).
Clinical rationale should address expected benefit given diminished ovarian reserve and informed consent discussions about success probabilities.

Note

GnRH suppression not established

Gonadotropin-releasing hormone (GnRH) agonists or antagonists for ovarian or testicular suppression are considered controversial and not established as effective fertility preservation methods. Providers should not rely on GnRH suppression alone for fertility preservation and must document use only when consistent with accepted guidelines or in the context of approved indications.

ASRM and ASCO note that evidence for ovarian suppression with GnRH analogs to preserve fertility is insufficient/controversial.
GnRH analog therapy for fertility preservation in males has failed to demonstrate effectiveness per guideline statements.
When GnRH suppression is proposed, include supporting evidence in the clinical record and clarify that it is not a substitute for established preservation methods (oocyte/embryo cryopreservation, sperm cryopreservation, ovarian tissue cryopreservation when applicable).

Documentation Required

Provider action: prior authorization, documentation, and coding cautions

Providers must follow plan prior authorization requirements, submit complete clinical documentation to support medical necessity, and be aware that coverage decisions are subject to all terms, conditions, exclusions and limitations of the member's/enrollee's contract. Inclusion or exclusion of codes in this policy does not guarantee coverage; reference current coding guidance when submitting claims.

Submit prior authorization requests with complete clinical records, including the documentation specified above (age 40+ assessments, ovarian tissue malignancy status, timing constraints for retrieval, etc.).
Be aware that state Medicaid provisions may supersede this policy and that Medicare NCDs/LCDs must be reviewed for Medicare members.
Coding guidance: inclusion/exclusion of codes is informational only; providers must reference up-to-date professional coding sources when billing.

Collection and freezing of sperm for future use (sperm cryopreservation).

Established statusIdentified as the only established fertility preservation method for those with a male reproductive system (per ASCO).

Evidence on hormonal methodsHormonal therapy (GnRH analogs) has not shown effectiveness for fertility preservation in males and is not considered established.

Related proceduresIncludes sperm extraction and retrieval procedures when clinically indicated prior to gonadotoxic treatment.

Clinical policy — Guideline to assist coverage decisions (not medical advice or guarantee of payment)

Purpose of policyThis clinical policy provides guidance to assist in making coverage decisions and administering benefits; it is not medical advice.

Not a guarantee of paymentThe policy does not constitute a contract or guarantee regarding payment or results; coverage is subject to terms and limitations of the member's benefit documents and applicable law.

Provider responsibilityProviders must exercise professional medical judgment; the policy does not dictate clinical care or replace provider decision-making.

Regulatory precedenceIf discrepancies exist with legal or regulatory requirements, laws and regulations govern; state Medicaid provisions take precedence where applicable.