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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 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).
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.
Medically Necessary - Individuals with female reproductive system
Covered when ALL of the following are met:
ALL of the following
Ovarian tissue retrieval specific
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
The following procedures are considered to have insufficient evidence and are not supported for fertility preservation:
ANY of the following
Listed as insufficient evidence / controversial
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
Covered when ALL of the following are met:
ALL of the following
Requirement: performed prior to gonadotoxic treatment
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
Listed as experimental/insufficient evidence
Listed as ineffective / insufficient evidence
| 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. |
| 53899 | Unlisted procedure, urinary system. |
| 55899 | Unlisted procedure, male genital system. |
| 89398 | Unlisted reproductive medicine laboratory procedure. |
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.
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.
Providers should reference the separate cryopreservation policy CP.MP.55 for technical coverage details related to cryopreservation procedures and related services.
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.
Policy effective date.
Documentation threshold: age 40 triggers required provider assessment and documentation.
Pre-procedure documentation for female members/enrollees age 40
For female members/enrollees age 40 requesting retrieval of their own oocytes, the treating provider must document that they have evaluated the member's age, infertility risk factors, and a measure of ovarian reserve, and that they consider use of the member/enrollee's own oocytes a viable strategy for attempting future conception.
Ovarian tissue malignancy exclusion
Ovarian tissue retrieval is excluded when ovarian tissue is known or suspected to contain malignancy; tissue must be evaluated and documented as free from malignancy prior to cryopreservation or consideration for future reimplantation.
Prior to gonadotoxic treatment
Prior to commencing gonadotoxic therapy, fertility preservation procedures must be performed. Coverage applies when the treatment causing the infertility risk is medically necessary (excluding voluntary sterilization).
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.
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.
Last review date.