Fidelis Care Fertility Preservation Coverage

Coverage Criteria and Exclusions for Fertility Preservation

Medically necessary fertility preservation procedures

Covered when ALL of the following are met for persons prior to commencing treatment likely to cause infertility and when the service is a covered benefit under the member's contract:

Female reproductive system - pre-treatment: Ovarian stimulation and retrieval of oocytes are medically necessary prior to commencing treatment likely to cause infertility (excluding voluntary sterilization).

Includes ovarian tissue retrieval when tissue is free from malignancy or when insufficient time for oocyte retrieval or member is prepubertal; ovarian transposition (oophoropexy) is included.

Male reproductive system - pre-treatment: Cryopreservation of sperm and radiation (gonadal) shielding are medically necessary prior to commencing treatment likely to cause infertility (excluding voluntary sterilization).

For adults and adolescents with a male reproductive system, sperm extraction and retrieval procedures are medically necessary prior to commencing medically necessary treatment likely to cause infertility.

Investigational procedures

Procedures considered investigational / not covered when intended for fertility preservation prior to treatment likely to affect fertility:

Female investigational: Ovarian suppression with gonadotropin releasing hormone (GnRHa) or antagonists is investigational and not a covered benefit for women and adolescent girls prior to commencing treatment likely to affect fertility.

Male investigational: Testicular suppression with GnRHa or antagonists and reimplantation or grafting of human testicular tissue are investigational and not a covered benefit for men and adolescent boys prior to commencing treatment likely to affect fertility.

Not covered / exclusions

Explicitly not covered cryopreservation-related services and other exclusions:

Excluded services: Cryopreservation intended for donor oocytes or donor sperm; in vitro fertilization; cryopreservation and storage of embryos; gamete intrafallopian tube transfers or zygote intrafallopian tube transfers; cryopreservation and storage of sperm and ova except when performed as fertility preservation services; costs associated with an ovum or sperm donor (including the donor's medical expenses); ovulation predictor kits; reversal of tubal ligations; reversal of vasectomies; costs for surrogate motherhood not otherwise covered; cloning; medical and surgical procedures that are experimental or investigational (unless overturned by an External Appeal Agent); and percutaneous epididymal sperm aspiration (PESA) and testicular sperm aspiration (TESA) intended for in vitro fertilization to treat infertility are not covered.

Includes donor-related costs and PESA/TESA when intended for IVF to treat infertility.

The policy specifies services that are explicitly not covered when billed as fertility preservation. Not covered items include: cryopreservation and storage of embryos; in vitro fertilization (IVF); cryopreservation intended for donor oocytes or donor sperm; gamete or zygote intrafallopian transfers; cryopreservation and storage of sperm and ova except when performed as fertility preservation services; donor-related costs; reversal of sterilization procedures; surrogate motherhood costs not otherwise covered; cloning; and experimental procedures. The policy also notes that procedures such as PESA and TESA intended for IVF to treat infertility are excluded.

Coverage under this clinical policy is subject to the terms, conditions, exclusions and limitations of the member's coverage documents. This policy is a guide to medical necessity and does not guarantee payment; coverage decisions and administration of benefits are governed by the member's evidence of coverage, certificate of coverage, policy or contract of insurance, and applicable state and federal requirements. The Health Plan may change, amend or withdraw this clinical policy and providers should verify prior authorization and coverage per applicable Health Plan procedures and the member's contract.

The evidence for ovarian suppression with GnRHa or antagonists and testicular suppression with GnRHa or antagonists as methods of fertility preservation is inconclusive. The policy considers these approaches investigational and not a covered benefit for women, adolescent girls, men, or adolescent boys when used for fertility preservation prior to commencing gonadotoxic treatment.

Relevant Procedure, HCPCS, and Laboratory Codes

Covered CPT CodesCPTCovered

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)
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
82670	Estradiol
83001	Gonadotropin; follicle stimulating hormone (FSH)

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Covered HCPCS CodesHCPCSCovered

S4030	Sperm procurement and cryopreservation services; initial visit
S4031	Sperm procurement and cryopreservation services; subsequent visit

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for fertility preservation procedures when the service is a covered benefit under the member's benefit plan contract. Providers must obtain prior authorization before performing services such as ovarian stimulation and oocyte retrieval, ovarian tissue retrieval, cryopreservation of sperm, sperm extraction/retrieval, gonadal shielding, and related fertility preservation procedures described in policy CP.FC.15.

Affected services: oocyte retrieval, ovarian tissue retrieval/transposition, cryopreservation of sperm, sperm extraction/retrieval, gonadal shielding.
Prior authorization cross-reference: Centene Clinical Policy CP.MP.130 and applicable member contracts.

Note

Verify Prior Authorization and Coverage

Verify prior authorization requirements and member coverage prior to scheduling. Confirm that the requested fertility preservation service is a covered benefit under the member's evidence of coverage/certificate of coverage and check for any Health Plan-level administrative requirements or limitations. Ensure eligibility and benefit determination reflect current 2024 EPP and HBX contract language.

Clinical Background and Rationale

Medical treatments such as cytotoxic chemotherapy, radiation, or surgery can transiently or permanently impair fertility; the degree of risk depends on the type of treatment, dose, field size, patient age, and other factors. Established fertility preservation options described in the policy include ovarian stimulation and retrieval of oocytes, ovarian tissue retrieval (including ovarian transposition when tissue is free of malignancy or when there is insufficient time for oocyte retrieval or the member is prepubertal), sperm cryopreservation, radiation (gonadal) shielding, and sperm extraction or retrieval for adults and adolescents with a male reproductive system. The policy emphasizes these interventions are intended to be performed prior to commencing treatment likely to cause infertility (excluding voluntary sterilization).

Key Definitions

Iatrogenic infertility — definition

Definition'Iatrogenic infertility' means an impairment of fertility by surgery, radiation, chemotherapy or other medical treatment affecting reproductive organs or processes.

Causes includedSurgery, radiation, chemotherapy, or other medical treatments that affect reproductive organs or processes.

Clinical relevanceFidelis covers standard fertility preservation services when medical treatment will directly or indirectly lead to iatrogenic infertility.

Examples of preservation servicesCollecting, preserving, and storing of ova or sperm prior to gonadotoxic therapy.