CurrentFidelis CarePolicy CP.FC.14

Ovulation Induction and Infertility

Defines medical necessity, coverage limits, and coding for ovulation induction and related infertility diagnostic and treatment services for Fidelis Care Medicaid members aged 21-44. Applies to Medicaid line of business only.

Policy Summary

PayerFidelis Care

PolicyOvulation Induction and Infertility

Policy CodePolicy CP.FC.14

Change TypeNo material change

Effective DateOct 1, 2019

Next Review Date

Key ActionObtain prior authorization for listed ultrasound and hysterosalpingography CPT codes when used for infertility services; ensure required documentation of diagnosis and duration of infertility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3lifetime drug cycles

21-44eligible age range

3pelvic US limit (per cycle / lifetime)

176831 & 74740 limit

58321-58323not covered (AI/sperm wash)

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.

Ovulation induction — Medical necessity criteria

Covered when ALL of the following are met

Basic Criteria: 1) Diagnosis of one of: hypogonadotropic hypogonadism (HA), polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI), or hyperprolactinemia; 2) Use of and monitoring of ovulation induction performed by a physician board-certified or board-eligible in Obstetrics & Gynecology or Reproductive Endocrinology; 3) Fertility is naturally expected and there is documentation of inability to conceive: 12 menstrual cycles of exposure to sperm for ages 21-34 OR 6 cycles for women ≥ age 35.

See Table 1 ICD-10 codes for supported diagnoses.

Treatment-specific Criteria: 1) Lifetime limit: ovulation-enhancing drugs limited to 3 cycles; 2) For PCOS, letrozole should be considered first-line therapy; 3) Pelvic ultrasounds limited to 3 per cycle for up to 3 cycles total per lifetime and require an initial prior authorization; additional ultrasounds require prior authorization; 4) CPT codes 76831 and 74740 are limited to 1 per lifetime and must be associated with a covered infertility diagnosis from Table 1.

Imaging and ultrasound limits require prior authorization as specified.

The policy excludes a range of services from coverage. Specifically, any experimental infertility procedure remains excluded until it is recognized as nonexperimental. Coverage also excludes services related to surrogacy, reversal of voluntary sterilization, and commercially available over‑the‑counter home test kits (including ovulation prediction and pregnancy test kits). Additionally, infertility services needed as a result of prior voluntary sterilization or unsuccessful sterilization reversal are excluded, as are partner infertility services when the partner is not a member. Infertility due solely to natural aging in women older than 44 years or menopausal women is not covered, and procedures for gender selection or chromosomal studies of donor sperm or egg are likewise excluded.

The policy lists services and indications that are considered not medically necessary and therefore may be denied. These include experimental infertility procedures (until proven nonexperimental), services supporting surrogacy, reversal of voluntary sterilization, over‑the‑counter home test kits, infertility treatment required because of prior voluntary sterilization or failed sterilization reversal, partner services when the partner is not a member, infertility caused by natural aging (> 44) or menopause, and gender selection or chromosomal testing of donor gametes.

Billing and Coding

Covered CPT Codes (with diagnosis from Table 1)CPTCovered

76830	Ultrasound, transvaginal
76831	Saline infusion sonohysterography (SIS), including color flow Doppler, when performed
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
76857	Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)
74740	Hysterosalpingography, radiological supervision and interpretation

CPT codes not coveredCPTNot Covered

58321	Artificial insemination; intracervical
58322	Artificial insemination; intrauterine
58323	Sperm washing for artificial insemination

ICD-10 diagnosis codes supporting coverageICD-10

E22.1	Hyperprolactinemia
E28.2	Ovarian dysfunction (documented as E28-28.x in policy)
E23.0	Hypogonadotropic hypogonadism
L68.0	Hirsutism
N97.0	Female infertility associated with anovulation
N97.8	Female infertility of other origin
N97.9	Female infertility, unspecified
Z31.41	Encounter for fertility testing

inv-07: Lifetime ovulation-enhancing drug cycles — numeric limit

Lifetime cycles allowed3 cycles of treatment per lifetime for FDA‑approved ovulation‑enhancing medications (clomiphene, bromocriptine, letrozole, tamoxifen)

Covered medication groupingMedications are covered as a group and not individually (females: clomiphene, bromocriptine, letrozole, tamoxifen)

Documentation linkageUse is subject to the policy's basic criteria including diagnosis of anovulation and required clinical documentation

inv-08: Pelvic ultrasound limit — 3 per cycle for 3 cycles lifetime, initial PA required

Per‑cycle limitUp to 3 pelvic ultrasounds per treatment cycle

Lifetime totalLimit applies for up to 3 cycles total per lifetime (i.e., 3 ultrasounds × 3 cycles)

Prior authorizationInitial prior authorization required; any additional ultrasounds beyond limits require prior authorization

inv-09: CPT 76831 & 74740 limit — 1 per lifetime

CPT 76831 & 74740 lifetime limitEach of CPT 76831 and CPT 74740 is limited to 1 per lifetime when used for infertility services (requires a covered diagnosis from Table 1)

Prior authorizationThese imaging codes require prior authorization for infertility services and must be associated with an eligible diagnosis from Table 1

Related imaging limitsOther pelvic ultrasound codes (76830, 76856, 76857) have separate lifetime limits and PA requirements per policy

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain ultrasound and hysterosalpingography (HSG) CPT codes when used for infertility services. Submit PA with supporting clinical documentation demonstrating the infertility diagnosis and that the requested service meets policy criteria.

PA required for CPT codes: 76830, 76831, 76856, 76857, 74740 when performed for infertility
Limits: 76830, 76856 & 76857 limited to 10 per lifetime; 76831 & 74740 limited to 1 per lifetime
Additional ultrasounds beyond benefit limits require prior authorization

Note

First-line Medication Preference

Letrozole (aromatase inhibitor) is the preferred first-line medication for ovulation induction in individuals with polycystic ovary syndrome (PCOS).

Documentation Required

Required Clinical Documentation

Documentation must accompany prior authorization requests and medical records to support medical necessity. Include diagnosis, duration of infertility per age group, treating provider specialty, and details of previous treatments and monitoring.

Required: diagnosis consistent with policy (anovulation causes such as HA, PCOS, POI, hyperprolactinemia)
Required: documentation of inability to conceive — 12 months of exposure to sperm for ages 21-34, or 6 months for ages 35-44
Required: treating clinician board-certified/eligible in Obstetrics & Gynecology or Reproductive Endocrinology
Required: prior treatment history, number of prior ovulation induction cycles, and number of ultrasounds performed

Denial Risk

Not Medically Necessary Conditions

The following services and indications are considered not medically necessary for ovulation induction/infertility services and will be denied if billed as such.

Any experimental infertility procedure until it is recognized as nonexperimental
Surrogacy-related services
Reversal of voluntary sterilization
Commercially available over-the-counter home test kits (e.g., ovulation prediction and pregnancy test kits)
Infertility treatment for conditions resulting from prior voluntary sterilization or unsuccessful sterilization reversal
A partner's infertility services when the partner is not a Fidelis Care member
Members who are medically infertile due to natural aging (>44) or who are menopausal
Gender selection and chromosomal studies of donor sperm or egg
CPT codes 58321-58323 are not covered for infertility services

Background

Ovulatory disorders account for a substantial proportion of infertility presentations. Ovulation induction is used to treat anovulation from causes such as hypogonadotropic hypogonadism (HA), polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI), and hyperprolactinemia. Treatment involves physician‑directed use of ovulation‑enhancing medications with monitoring (office visits, blood tests, and pelvic ultrasound), and the policy defines clinical and monitoring requirements to support medical necessity (see coverage criteria).

Definitions

inv-15: Polycystic ovary syndrome (PCOS) — Rotterdam criteria summary

Rotterdam criteria overviewDiagnosis requires at least 2 of 3 features: 1) oligo‑ and/or anovulation; 2) clinical and/or biochemical hyperandrogenism; 3) polycystic ovaries on ultrasound (≥12 follicles 2–9 mm or ovarian volume >10 cm³)

Clinical signs of hyperandrogenismClinical: hirsutism or male‑pattern alopecia; Biochemical: elevated free androgen index or free testosterone

Epidemiology noteWomen with PCOS represent the largest group of anovulatory women (70–85% of cases)

inv-16: Primary ovarian insufficiency (POI) — definition and scope

DefinitionDepletion or dysfunction of ovarian follicles with cessation of menses before age 40 years; represents a spectrum of declining ovarian function

Clinical scopeResults in reduced fecundity due to premature decrease in follicle number, increased follicle destruction, or poor follicular response to gonadotropins

Age thresholdCessation of menses occurring before age 40 meets the definition

inv-17: Hyperprolactinemic anovulation — definition and clinical features

DefinitionElevated prolactin leading to irregular or absent menstrual periods, possible galactorrhea (abnormal breast milk discharge), and infertility

Clinical featuresIrregular/absent menses and abnormal lactation are typical presenting signs

Implication for treatmentIdentifying hyperprolactinemia as a cause of anovulation guides targeted medical management

inv-18: Hypogonadotropic hypogonadism (HA) — definition and causes

DefinitionLow serum estradiol with low or low‑normal FSH due to decreased hypothalamic GnRH secretion (hypogonadotropic hypogonadism)

CausesIncludes functional hypothalamic amenorrhea (eg, from low weight, eating disorders, excessive exercise, stress) and isolated GnRH deficiency

Biochemical findingsLow estradiol and low or low‑normal FSH concentrations on testing

inv-19: Unexplained infertility — definition when standard evaluation is normal

DefinitionInfertility remaining after a standard evaluation (patent fallopian tube, documented ovulation, adequate semen analysis) finds no treatable cause

Evaluation componentsStandard evaluation typically includes confirmation of at least one patent tube, evidence of ovulation, and semen analysis showing adequate motile sperm

Treatment approachManagement is empiric; common options include ovarian stimulation with oral agents or injectable gonadotropins often combined with intrauterine insemination (IUI)

OpenPayer

Ovulation Induction and Infertility

Coverage Criteria for Ovulation Induction and Infertility Services

Billing and Coding

Provider Requirements and Prior Authorization

Background

Definitions