CurrentHealth NetPolicy HNCA.CP.MP.55

Assisted Reproductive Technology

Defines medical necessity criteria, covered procedures, exclusions, provider qualifications, and coding references for assisted reproductive technologies (ART) for Health Net members/enrollees whose benefit plans cover infertility services. Applies to female and male reproductive system treatments, cryopreservation, surrogacy-related testing, and related laboratory procedures when plan benefits authorize infertility services.

Policy Summary

PayerHealth Net

PolicyAssisted Reproductive Technology

Policy CodePolicy HNCA.CP.MP.55

Change TypeMaterial updates (surrogacy addedSB 729 complianceassisted hatching added)

Effective Date

Next Review Date

Key ActionDocument provider board-certification/eligibility, infertility duration/evaluation, and follow benefit plan authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Added section 11 for Surrogacy and updated definition of infertility; reformatted policy.

Policy updated for Health Net of California to reflect changes to Large Group coverage mandates related to DMHC APL SB729; Assisted Hatching (89253) added to medically necessary procedures.

Annual reviews with multiple edits to criteria (provider qualifications, IVF/IUI criteria, age limits, cryopreservation durations) over prior years.

11Major ART sections/indications listed

30+CPT/HCPCS codes listed

3Cryopreservation storage durations

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39Reference list length

Coverage Summary

Scope: This policy applies to Health Net members/enrollees whose benefit plan covers infertility services and defines medical necessity for Assisted Reproductive Technology (ART) services. It applies to treatments for both female and male reproductive systems, including clinical and laboratory procedures that handle human oocytes, sperm, or embryos to establish pregnancy.

Overview: Major covered services include assisted reproductive technologies (ART) such as in vitro fertilization with embryo transfer (IVF-ET), frozen embryo transfer (FET), intrauterine/intracervical insemination (IUI/ICI), intracytoplasmic sperm injection (ICSI), gamete/zygote intrafallopian transfer (GIFT/ZIFT), testicular/epididymal sperm extraction (TESE/MESA), cryopreservation of sperm/oocytes/embryos, and surrogacy-related medically necessary testing for the surrogate when applicable. The policy references professional guidance (e.g., ASRM limits on number of embryos to transfer) for procedure-specific limits.

Coverage note: Coverage is subject to the member/enrollee's benefit plan contract, including any plan-specific limitations, and services require authorization as defined by the member's plan.

Key thresholds from policy

Duration to document infertility12 months of cycles exposed to sperm (or 6 months for female reproductive system age ≥ 35)

Frozen embryos threshold for IVF eligibility< 3 embryos for female reproductive system age < 35; < 4 embryos for female reproductive system age ≥ 35

High response estradiol thresholdEstradiol > 1000 pg/ml

Follicle count threshold for IUI->IVF conversionAt least 3 follicles ≥ 16 mm OR 4–8 follicles > 14 mm

Severe male infertility sperm concentrationSperm concentration < 10 million/mL

ICSI trigger sperm motility thresholdLess than 2 million motile spermatozoa per ejaculate

Semen analysis thresholds for vasectomy reversal success evidenceTwo recent normal semen analyses within past 3 months: sperm count > 20 million/ml; motility > 50%; morphology > 14% normal forms by Krüger or > 30% normal forms by WHO

Medical Necessity Criteria

General policy statement

ART is medically necessary for indicated infertility diagnoses when both the basic and treatment-specific criteria are met and the member/enrollee's benefit plan covers infertility services.

General policy statement: Member/enrollee's benefit plan covers infertility services; refer to benefit guidelines for limitations

Coverage is subject to the member/enrollee benefit plan contract

I. Basic Criteria

Covered when ALL of the following Basic Criteria are met:

I. Basic Criteria - top level

Provider qualification: ART is performed by a physician board-certified or board-eligible in reproductive endocrinology for those with a female reproductive system; and by a board-certified or board-eligible urologist or reproductive endocrinologist for those with a male reproductive system

Coding

CPT codes that support medical necessity (listed)CPTCovered

58321	Artificial insemination; intra-cervical
58322	Artificial insemination; intra-uterine
58323	Sperm washing for artificial insemination
58970	Follicle puncture for oocyte retrieval, any method
58974	Embryo transfer, intrauterine
58976	Gamete, zygote, or embryo intrafallopian tube transfer; any method
89250	Culture of oocyte(s)/embryo(s), less than 4 days
89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture
89253	Assisted Embryo Hatching, Microtechniques (Any Method)
89254	Oocyte identification from follicular fluid

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HCPCS S-code case rates and proceduresHCPCSCovered

S4011	In vitro fertilization; complete procedure
S4013	Complete cycle, GIFT, case rate
S4014	Complete cycle, ZIFT, case rate
S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016	Frozen in vitro fertilization cycle, case rate
S4017	Incomplete cycle, treatment canceled prior to stimulation, case rate
S4018	Frozen embryo transfer procedure canceled before transfer, case rate
S4020	IVF procedure canceled before aspiration, case rate
S4021	IVF procedure canceled after aspiration, case rate
S4022	Assisted oocyte fertilization, case rate

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Provider Actions & Documentation Requirements

Documentation Required

Provider qualification documentation

Document that the treating physician is board-certified or board-eligible in reproductive endocrinology for care of those with a female reproductive system, or is a board-certified or board-eligible urologist or reproductive endocrinologist for care of those with a male reproductive system.

Documentation Required

Infertility duration and evaluation documentation

Document inability to conceive for the required duration (12 months of cycles exposed to sperm, or 6 months if the person with a female reproductive system is age ≥ 35). Document evaluation that no untreatable anatomic cause exists, consideration/modification of modifiable causes, and for those ≥ age 40 using their own oocytes, documentation that the provider evaluated age, infertility risk factors, ovarian reserve, prior treatments and responses, and considers use of the member's own oocytes a viable strategy.

Background & Definitions

Background: Assisted Reproductive Technologies (ART) are procedures and laboratory techniques that involve handling human oocytes, sperm, or embryos with the intent of establishing pregnancy. The policy limits application to members/enrollees whose plans provide infertility benefits.

ASRM guidance and embryo transfer limits: The policy incorporates ASRM guidance on limits to the number of embryos to transfer (see Table 1) when determining medical necessity for embryo transfer and frozen embryo transfer (FET).

Infertility definition and duration thresholds: Infertility is defined by physician findings and failure to achieve pregnancy after 12 months of regular unprotected intercourse for persons <35 years of age or 6 months for those ≥35 years of age; this definition informs eligibility for ART when the member's plan covers infertility services.

Term	Definition
Infertility
A condition characterized by physician findings based on history, age, physical findings, diagnostic testing; inability to reproduce without medical intervention; failure to establish pregnancy or carry to live birth after regular unprotected intercourse (12 months if under 35; 6 months if 35 or older).
Donor
An individual from whom eggs, sperm, or embryos are obtained through means other than through sexual intercourse.
Surrogacy
A person who bears and carries a child for another through medically assisted reproduction pursuant to a written agreement.

Revision History

4/26addedLatest

Added section 11 for Surrogacy and updated definition of infertility; reformatted policy.

2/26revised

Policy updated for Health Net of California to reflect changes to Large Group coverage mandates related to DMHC APL SB729; Updates made in accordance with APL-021 (Dec 30, 2025; updated Feb 23, 2026); updated definition of infertility.

10/25revised

Policy Summary

PayerHealth Net

PolicyAssisted Reproductive Technology

Policy CodePolicy HNCA.CP.MP.55

Change TypeMaterial updates (surrogacy addedSB 729 complianceassisted hatching added)

Effective Date

Next Review Date

Key ActionDocument provider board-certification/eligibility, infertility duration/evaluation, and follow benefit plan authorization requirements.

SourceLink

On This Page

Document provider board-certification/eligibility

Anatomic and modifiable causes: There is no untreatable anatomic cause of infertility and modifiable causes of infertility not addressed within this policy have been considered and modified if possible

Infertility duration: Documentation of inability to conceive during a period of 12 months of cycles exposed to sperm (including IUI), or six months for those with a female reproductive system age ≥ 3512 months or 6 months if age ≥ 35

Record duration of unprotected intercourse/cycles

Age ≥ 40 using own oocytes: For those with a female reproductive system ≥ age 40 attempting conception using their own oocytes, documentation that treating provider evaluated age, infertility risk factors, measures of ovarian reserve, prior treatment and response, and considers use of the member/enrollee's own oocytes a viable strategy

Document ovarian reserve and prior response

Infertility unrelated to voluntary sterilization or failed reversal evidence (ONE of): Infertility is unrelated to voluntary sterilization or failed reversal of voluntary sterilization of either partner. Evidence of reversal failure: vasectomy reversal — two recent normal semen analyses within past three months with specified thresholds; tubal reanastomosis — hysterosalpingogram showing unilateral or bilateral tubal patency.semen and imaging thresholds specified

Semen thresholds: sperm count > 20 million/ml; motility > 50%; morphology > 14% Krüger or > 30% WHO

II. Treatment-Specific Criteria

Covered when the specific treatment criteria below are met in addition to Basic Criteria. Each numbered treatment group below reflects the policy's required AND/OR/N-of logic.

II. Treatment-Specific Criteria - Procedures meeting criteria (ONE of)

1. Artificial Insemination (ICI/IUI)
- Tubal patency requirement: Unilateral or bilateral tubal patency
- AND one of
  - OR special circumstances (ONE of): Unable or very difficult to have vaginal intercourse due to clinically diagnosed physical disability or psychosexual problem using partner or donor sperm; couples with male partner HIV positive undergoing sperm washing; member/enrollee with female reproductive system without male partner using donor sperm.
    These do not require demonstration of 6-12 months or treatment by reproductive endocrinologist
2. In Vitro Fertilization with Embryo Transfer (IVF-ET)
- Embryo availability: Inadequate number of frozen embryos available for transfer: < three for female reproductive system age <35, or < four for female reproductive system age ≥35<3 (<35) or <4 (≥35)
- AND at least one of
  - Barrier to fertilization (ONE of): Bilateral fallopian tube absence or obstruction due to prior tubal disease (not voluntary sterilization); endometriosis-associated infertility failing treatment; severe male reproductive system infertility failing conservative treatments (sperm concentration <10 million/mL and/or normal morphology ≤1% Krüger/≤5% WHO); prior IVF cycle with failed or poor fertilization.sperm <10 million/mL; morphology thresholds as specified
  - High response to medicated IUI to be converted to IVF: Estradiol level of > 1000 pg/ml AND production of at least three follicles ≥ 16 mm or four to eight follicles > 14 mm in diameterEstradiol > 1000 pg/ml; follicles ≥16mm (≥3) or 4–8 >14mm
3. Frozen Embryo Transfer (FET)
- ASRM embryo transfer limits: Number of embryos to transfer per attempt meets requirements in Table 1 (ASRM limits).ASRM Table 1
- AND one of: Female reproductive system <35 with at least three embryos available for transfer OR female reproductive system ≥35 with at least four embryos available for transfer<35: ≥3; ≥35: ≥4
4. GIFT / ZIFT
- Patent tube: Member/enrollee has at least one patent fallopian tube
- Indications (ONE of): Utilization of cryopreserved sperm and an oocyte or embryo(s) obtained for fertility preservation OR unexplained infertility
- Prior IUI cycles for females: For female reproductive system, at least 3 previous unsuccessful cycles of ovarian stimulation with oral agents followed by IUI3 unsuccessful cycles
- Justification that GIFT/ZIFT is preferable to standard IVF
5. Intracytoplasmic Sperm Injection (ICSI) - meets ONE of
- Primary ICSI indications: Less than two million motile spermatozoa per ejaculate; anti-spermatozoan antibodies contributing to infertility; prior or repeated fertilization failure with standard IVF protocols (<50% fertilization); washed sperm limited in number and quality; obstruction of male tract not amenable to repair necessitating MESA/TESE (not due to voluntary sterilization); abnormal morphology (≤1% Kruger; ≤5% WHO); specific sperm defects impairing sperm-oocyte interaction; fertilization of previously frozen oocytes and in vitro matured oocytes; utilization of cryopreserved sperm and/or oocyte for fertility preservation.<2 million motile sperm; morphology thresholds specified; prior fertilization <50%
- Additional indicated scenarios (ONE of): HIV or hepatitis-discordant couples; need for preimplantation genetic testing for monogenic disorders (PGT-M) requiring absence of extraneous DNA; treatment of elected types of female infertility such as morphologic oocyte anomalies or zona pellucida anomalies.
6. Donor egg cycle - meets ONE of: Member/enrollee with a female reproductive system meets one or more of: congenital/surgical absence of ovaries; premature ovarian failure (menopause before age 40); diminished ovarian reserve; ovarian failure after radiation/chemotherapy; previously failed IVF in those >40; gonadal dysgenesis including Turner syndrome; high risk of transmitting genetic disorder from female reproductive system; hypergonadotropic hypogonadism.
7. TESE / micro-TESE / epididymal sperm extraction: For male reproductive system with obstructive or non-obstructive azoospermia.
8. Donor sperm - meets ONE of
- Donor sperm indications list: Partner with male reproductive system has bilateral congenital absence of the vas deferens; ejaculatory dysfunction; obstructive azoospermia, severe oligozoospermia, or other significant semen abnormalities; those with a female reproductive system without a male partner; high risk of transmitting infectious disease (e.g., HIV); high risk of transmitting genetic disorder from male partner; partner has non-obstructive azoospermia confirmed by MESA/TESA; couples incompatible for red cell antigens with history of severely affected infant; partner had previous radiation/chemotherapy causing abnormal semen analysis; partner had two abnormal semen analyses at least 30 days apart; failure of at least three cycles IVF or ICSI.
9. Cryopreservation of sperm (male): Covered for a member/enrollee with a male reproductive system already in active infertility treatment who has undergone an approved MESA or TESE procedure. Storage duration per group: Large Group 5 years; Small Group at least 1 year.Storage: LG 5 years; SG ≥1 year
See fertility preservation policy for non-elective treatments
10. Cryopreservation of mature oocytes: Covered if meeting one of indications for cryopreservation of embryos but unable or unwilling for ethical reasons to cryopreserve embryos. Storage duration per group: Large Group 5 years; Small Group at least 1 year.Storage: LG 5 years; SG ≥1 year
11. Surrogacy - medically necessary procedures for surrogate: When both criteria A and B are met: A) medical procedures for a covered member with infertility (infertility evaluation; ovarian stimulation; oocyte retrieval; fertilization) AND B) there is a confirmed medical contraindication to pregnancy for the intended parent. The plan covers medically necessary health testing of the surrogate for each attempt to collect gametes/create embryos and for each attempt to achieve pregnancy with that material.
Surrogate procedures covered only when both A and B met
Other covered services/procedures listed: Other covered services include infertility surgery (laparoscopy, myomectomy, hysteroscopic procedures, adhesiolysis, tubal procedures, tubal anastomosis, etc.); sperm washing for HIV-discordant couples; ICSI with or without assisted hatching; Frozen Embryo Transfer (FET); GIFT/ZIFT; assisted hatching in selected cases.

III. Not Medically Necessary (Exclusions)

ART is not medically necessary for the following exclusions:

III. Not Medically Necessary (Exclusions): Any experimental infertility procedure; reversal of voluntary sterilization; commercially available over-the-counter home test kits (e.g., ovulation prediction, pregnancy test kits); a partner's infertility services when the partner is not a member/enrollee unless mandated by benefits; those with a female reproductive system who are ≤ 54 years of age and are menopausal (unless using a donor egg for diminished ovarian reserve or ovarian failure); those with a female reproductive system who are > 55 years of age; gender selection and chromosomal studies of donor sperm or egg.

Authorization subject to benefit plan

Coverage of ART services is subject to the member/enrollee's benefit plan contract and any authorization limits; refer to the member's benefit guidelines for coverage limitations and authorization requirements.

Documentation Required

Evidence for sterilization reversal

For cases related to reversal of voluntary sterilization: for vasectomy reversal provide two recent normal semen analyses within the past three months with thresholds (sperm count > 20 million/ml; motility > 50%; morphology > 14% normal forms by Krüger or > 30% normal forms by WHO). For prior tubal ligation with reanastomosis, provide a hysterosalpingogram documenting unilateral or bilateral tubal patency.

Billing Rule

Use of CPT/HCPCS coding reference

Reference Current Procedural Terminology (CPT) and HCPCS coding guidance when billing; the listed CPT/HCPCS codes in this policy are informational and inclusion does not guarantee coverage—providers should reference the most up-to-date professional coding guidance prior to claim submission.

Documentation Required

Surrogate testing coverage requirement

When a surrogate is used, the member's plan covers medically necessary health testing of the surrogate as necessary for each attempt to collect eggs or sperm or to create embryos, and for each attempt to achieve a pregnancy with that material when the surrogate criteria are met.

Documentation Required

Follow state Medicaid precedence when applicable

For Medicaid members/enrollees, state Medicaid coverage provisions take precedence over this clinical policy when they conflict; providers must refer to the state Medicaid manual for applicable coverage provisions.

Documentation Required

Check Medicare NCDs/LCDs prior to application

For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying the criteria in this clinical policy to ensure consistency with Medicare coverage.

Note

Exercise professional medical judgment

This clinical policy is intended as guidance to assist coverage decisions; providers are expected to exercise professional medical judgment in providing appropriate care and are responsible for treatment decisions. The policy does not guarantee payment or dictate care.

Policy updated for Health Net of California to accommodate changes made by DMHC APL SB729; Assisted Hatching (CPT 89253) added to medically necessary procedures.

2/25revised

Annual review with description updates and addition of ICSI and related criteria (including HIV/hepatitis-discordant couples and PGT‑M scenarios); removal of certain prior cryopreservation language.

2014–2026revised

Numerous revisions and annual reviews between 2014 and 2026 clarifying provider types, IVF/IUI/FET criteria, age limits, cryopreservation durations, CPT coding updates, and other treatment‑specific eligibility.

Prior ovarian stimulation cycles for IUI: For female reproductive system, at least 3 previous unsuccessful cycles of ovarian stimulation with oral agents followed by IUI3 unsuccessful cycles