CurrentCignaPolicy IP0091

Progesterone (Vaginal) for Individual and Family Plans

Defines prior-authorization and medical necessity criteria for vaginal progesterone (Endometrin) for Cigna individual and family plans, including use for infertility (ART) and prevention of preterm birth.

Policy Summary

PayerCigna

PolicyProgesterone (Vaginal) for Individual and Family Plans

Policy CodePolicy IP0091

Change TypeRevised coverage criteria and durations

Effective DateFeb 15, 2026

Next Review Date

Key ActionObtain prior authorization and submit documentation showing ART program use or indication for prevention of preterm birth to support approval and authorized duration.

SourceLink

POLICY UPDATE CHANGES

Infertility criterion clarified to require the medication be used to support embryo implantation and early pregnancy by supplementation of corpus luteal function AND as part of an ART treatment program.

Duration of therapy for infertility updated from 6 months to 9 months.

Duration of therapy for prevention of preterm birth updated from 6 months to 1 year.

Policy title changed from an Endometrin-specific title to 'Progesterone (Vaginal) for Individual and Family Plans'.

2covered indications

9 moART approval duration

1 yrPreterm birth duration

Endometrin

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Excludedplan exclusion risk

Coverage Criteria

Medically Necessary Indications

Progesterone (Endometrin) is considered medically necessary when ONE of the following is met (1 or 2):

1. Infertility: Approve for 9 months if the patient meets BOTH of the following (A and B): A) The medication is to be used to support embryo implantation and early pregnancy by supplementation of corpus luteal function; AND B) Use is indicated as part of an Assisted Reproductive Technology (ART) treatment program.duration=9 months

Both A and B required

2. Prevention of Preterm Birth: Approve for 1 year.duration=1 year

Supportive evidence basis

Fertility medications are specifically excluded under most benefit plans. Coverage for vaginal progesterone (Endometrin) therefore depends on the member’s applicable benefit plan document; providers should consult the plan’s terms and conditions to determine benefit availability.

Progesterone (Endometrin) for any other use is considered not medically necessary. This policy will be updated if new published data change the criteria.

Coding

No specific procedure or diagnosis codes listedmixed

No codes listed

Short cervix threshold for vaginal progesterone

Short cervix measurement< 25 mm (diagnosed between 16 and 24 weeks by transvaginal ultrasound)

Gestational windowDiagnosis between 16 and 24 weeks of pregnancy

Measurement methodTransvaginal ultrasound

Related recommendationVaginal progesterone recommended to reduce risk of spontaneous preterm birth for singleton pregnancy with short cervix

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for benefit coverage of vaginal progesterone (Endometrin). Approvals are provided for the duration specified by indication (see clinical criteria).

Prior authorization required for vaginal progesterone (Endometrin).
Approvals: Infertility (ART) — up to 9 months; Prevention of preterm birth — up to 1 year.

Documentation Required

Required Documentation

Requests for prior authorization should include documentation demonstrating the indication and clinical context for use (e.g., ART treatment program documentation for infertility or clinical evidence supporting prevention of preterm birth). All approvals will specify an authorized duration.

Include clinical documentation showing use to support embryo implantation and early pregnancy as part of an Assisted Reproductive Technology (ART) program when requesting coverage for infertility.

Background

Endometrin (vaginal progesterone) is used to support embryo implantation and early pregnancy by supplementing corpus luteal function as part of an Assisted Reproductive Technology (ART) treatment program. Vaginal administration achieves high uterine tissue levels and is recognized for both ART-related luteal support and certain obstetric indications such as prevention of preterm birth in select patients.

When applicable, prior authorization is required and approvals specify an authorized duration based on indication: for infertility as ART luteal support the approval duration is 9 months, and for prevention of preterm birth the approval duration is 1 year.

Definitions

Assisted Reproductive Technology (ART) — definition and context

ART (Assisted Reproductive Technology)Use of reproductive technologies in which Endometrin supports embryo implantation and early pregnancy as part of an ART treatment program

Endometrin descriptionProgesterone vaginal insert (Endometrin) — FDA‑approved formulation to support embryo implantation and early pregnancy by supplementing corpus luteal function

Non‑FDA compounded productsCompounded progesterone products (e.g., First‑Progesterone VGS) exist but are not FDA‑approved

Uterine tissue levelsVaginal administration achieves high uterine tissue levels compared with other routes

Endometrin — product definition

ProductEndometrin (progesterone vaginal insert)

Policy Summary

PayerCigna

PolicyProgesterone (Vaginal) for Individual and Family Plans

Policy CodePolicy IP0091

Change TypeRevised coverage criteria and durations

Effective DateFeb 15, 2026

Next Review Date

Key ActionObtain prior authorization and submit documentation showing ART program use or indication for prevention of preterm birth to support approval and authorized duration.

SourceLink

On This Page

For prevention of preterm birth requests, include supportive clinical documentation.

Authorizations will specify the approved duration based on the indication.

Billing Rule

Coding / Claim Compliance

Claims submitted without a covered diagnosis or procedure code under the applicable Coverage Policy will be denied as not covered. When billing, providers must use the most appropriate codes effective on the date of service and follow applicable coding/billing rules.

Claims lacking a covered diagnosis or procedure code per the applicable Coverage Policy will be denied as not covered.
Use the most appropriate diagnosis and procedure codes as of the date of service when submitting claims.

Denial Risk

Plan Exclusion / Benefit Determination

Fertility medications are specifically excluded under most benefit plans; coverage for progesterone (Endometrin) depends on the applicable benefit plan document. In the event of a conflict, the customer's benefit plan document supersedes this Coverage Policy.

Fertility medications are generally excluded under most benefit plans — verify the member's plan document for coverage availability and any applicable exclusions.
Coverage determinations require review of the applicable benefit plan document, relevant laws/regulations, this Coverage Policy, and the specific facts of the request.

IndicationSupports embryo implantation and early pregnancy by supplementation of corpus luteal function as part of an ART treatment program

FormulationFDA‑approved vaginal insert/tablet formulation

ComparisonAvailable progesterone formulations also include parenteral and oral products; some formulations are used to compound non‑FDA products