ModifiedHealth NetPolicy HNCP MP.55

Assisted Reproductive Technology (ART)

Defines medical necessity, covered ART procedures, and criteria for infertility treatments for members/enrollees whose benefit plans include infertility coverage; applies to both female- and male-reproductive-system patients when plan benefits allow.

Policy Summary

PayerHealth Net

PolicyAssisted Reproductive Technology (ART)

Policy CodePolicy HNCP MP.55

Change TypeAdded assisted hatchingclarified ICSI guidanceexpanded CPT/HCPCS lists

Effective Date

Next Review Date

Key ActionObtain prior authorization for ART services when the member's benefit includes infertility coverage and medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

Assisted Hatching (CPT 89253) added to medically necessary procedures.

ICSI recommended for patients with previously failed fertilization or very low sperm concentration/motility, with counseling about small potential neonatal risks.

Infertility services CPT/HCPCS lists and prior authorization requirements updated and expanded (multiple codes listed).

10+ART services listed

~50+CPT/HCPCS codes referenced

12m/6mInfertility definition

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Assisted Hatching added

1DMHC APL SB729 note

Medical Necessity and Coverage Rules for ART

Medical Necessity Criteria

ART is medically necessary when ALL of the Basic Criteria are met and when specific Treatment-Specific Criteria for the requested procedure are met.

Basic Criteria

Provider qualifications: ART must be performed by a physician board-certified or board-eligible in reproductive endocrinology for those with a female reproductive system; for those with a male reproductive system, by a board-certified or board-eligible urologist or reproductive endocrinologist.
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Anatomic and modifiable causes: No untreatable anatomic cause of infertility and modifiable causes considered and modified where possible (e.g., documented tubal patency after reanastomosis when applicable).
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Infertility duration: Documented inability to conceive during 12 months of exposure to sperm (including IUI) for those under age 35, or during 6 months for those with female reproductive systems age 35 or older.
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Treatment-Specific: IUI/ICI: IUI/ICI is covered when there is unilateral or bilateral tubal patency and one of the following indications: mild male factor infertility, unexplained infertility, cervical factors, sperm antibodies, endometriosis, use of cryopreserved sperm obtained for fertility preservation prior to gonadotoxic therapy, inability or extreme difficulty having vaginal intercourse (physical disability or psychosexual problem), HIV-positive male with sperm washing, or single/female-without-partner using donor sperm.

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Treatment-Specific: IVF with Embryo Transfer (IVF-ET): IVF-ET is indicated for barriers to fertilization (e.g., bilateral tubal absence/obstruction not due to voluntary sterilization), severe male factor infertility after failed conservative treatments, endometriosis-associated infertility after failed treatment, prior IVF with failed/poor fertilization, unexplained infertility meeting specified prior IUI failure criteria by age, high response to a medicated IUI cycle requiring conversion to IVF, and use of cryopreserved gametes/oocytes for fertility preservation.

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Treatment-Specific: Frozen Embryo Transfer (FET): FET is covered when: the number of embryos to transfer per attempt meets ASRM Table 1 limits; frozen embryos must be used to authorize additional IVF cycles in specified circumstances; if the member/enrollee continues to qualify for infertility, FET with fewer embryos available for transfer may still be medically necessary per policy note.

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Treatment-Specific: GIFT/ZIFT: GIFT/ZIFT is covered when all of the following are met: at least one patent fallopian tube is present; prior IUI failures per age criteria (e.g., <38: failure of three IUI cycles; 38–42: failure of at least one IUI cycle) where applicable; unexplained infertility criteria met; and justification that GIFT/ZIFT is preferable to standard IVF.

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Treatment-Specific: ICSI: ICSI is indicated when one or more of the following are present: <2 million motile sperm per ejaculate; anti-sperm antibodies contributing to infertility; prior or repeated fertilization failure with standard IVF; washed sperm limited in number/quality; obstruction of the male tract not amenable to repair requiring MESA/TESE (excluding voluntary sterilization); abnormal sperm morphology (<1% Kruger or <5% WHO); fertilization of previously frozen or in vitro matured oocytes; specific sperm defects impairing sperm–oocyte interaction; need for PGT-M or cases such as HIV/hepatitis-discordant couples.

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Donor gametes and surgical sperm retrieval: Donor egg is indicated for conditions such as congenital absence of ovaries, premature ovarian failure, ovarian failure after radiation/chemotherapy, diminished ovarian reserve, prior failed IVF (<=40), high genetic transmission risk, gonadal dysgenesis, and hypergonadotropic hypogonadism. TESE/micro-TESE/epididymal sperm extraction are indicated for obstructive or non-obstructive azoospermia. Donor sperm indicated for BCAVD, obstructive azoospermia, severe oligozoospermia, ejaculatory dysfunction, high infectious or genetic transmission risk, single females using donor sperm, incompatible red cell antigen couples, or partner non-member circumstances per policy.

chunk 12

Cryopreservation: Short-term cryopreservation of sperm or mature oocytes is covered during the initial year; extensions in 90-day increments beyond the initial year after the last approved infertility treatment are permitted when indications for fertility preservation are met.

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Clinical Indications (ICSI and Assisted Hatching)

Covered when clinically indicated and when prior authorization obtained if required by benefit:

ICSI indications: ICSI should be available for patients with previously failed fertilization and for patients whose sperm concentration and motility are too low to expect success with conventional IVF; patients should be counseled about small potential neonatal risks.

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Assisted Hatching indications: Assisted hatching may be used to assist implantation in selected poor-prognosis cases (e.g., multiple failed IVF, poor embryo quality, advanced maternal age); its use remains controversial. Assisted hatching (CPT 89253) has been added to the list of medically necessary procedures per policy update.

chunks 19,30,21

ART is considered not medically necessary for several specific situations. These include use of assisted reproductive services to support surrogacy, procedures characterized as experimental infertility procedures, and attempts to reverse a prior voluntary sterilization or to treat infertility that is the result of a prior voluntary sterilization or an unsuccessful sterilization reversal.

Inclusion of a procedure or a CPT/HCPCS code in this clinical policy does not by itself guarantee that the service will be covered. Coverage remains subject to the member's benefit terms, applicable exclusions and limitations, and correct coding and billing practices; providers must reference up-to-date professional coding guidance when submitting claims.

Coverage of ART services is governed by the member's specific coverage documents and the Health Plan's administrative policies. When state Medicaid provisions conflict with this clinical policy, the applicable state Medicaid provisions take precedence.

The policy explicitly excludes several additional items from medical necessity, including commercially available over-the-counter home test kits (for example, ovulation prediction and pregnancy tests), infertility services for a partner who is not a covered member/enrollee unless benefits mandate coverage, and certain age-based limits (e.g., those with a female reproductive system age 55, with specific exceptions for donor egg use in premature ovarian failure or diminished ovarian reserve). The policy also excludes services performed for nonmedical purposes such as gender selection and some chromosomal studies of donor gametes.

Historically, the policy language regarding assisted hatching changed over prior revisions. Earlier versions removed assisted hatching from the supported CPT code list, but subsequent updates reintroduced assisted hatching (CPT 89253) as a medically necessary procedure for selected clinical indications.

This clinical policy is intended to guide coverage determinations and does not constitute medical advice or direct clinical care. It is not intended to dictate how providers should practice medicine; clinicians are expected to exercise their professional judgment when treating members/enrollees.

CPT & HCPCS Codes and Embryo Transfer Limits

Coding implications headermixed

No codes listed

Infertility CPT Codes (partial list)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 (microtechnique) (Any method)
89254	Oocyte identification from follicular fluid

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Infertility CPT Codes (continued)CPTCovered

89264	Sperm identification from testis tissue, fresh or cryopreserved
89268	Insemination of oocytes
89272	Extended culture of oocyte(s)/embryo(s) 4-7 days
89280	Assisted oocyte fertilization, microtechnique; <=10 oocytes
89281	Assisted oocyte fertilization, microtechnique; >10 oocytes
89290	Microtechnique for pre-implantation genetic diagnosis; <=5 embryos (blastomere/oocyte body biopsy)
89291	Microtechnique for pre-implantation genetic diagnosis; >5 embryos
89337	Cryopreservation, mature oocyte(s)
89352	Thawing of cryopreserved embryo(s)
89353	Thawing of cryopreserved sperm/semen, each aliquot

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Infertility HCPCS/Supply CodesHCPCSCovered

S4011	In vitro fertilization; including identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization
S4013	Complete cycle, gamete intrafallopian transfer (GIFT) case rate
S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016	Frozen in vitro fertilization case rate cycle
S4017	Incomplete cycle, treatment canceled prior to stimulation, case rate
S4018	Frozen embryo transfer, procedure canceled before transfer, case rate
S4020	In vitro fertilization procedure canceled before aspiration, case rate
S4021	In vitro fertilization procedure canceled after aspiration, case rate
S4022	Assisted oocyte fertilization, case rate
S4025	Donor services for in vitro fertilization (sperm or embryo) case rate

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Number of embryos available for transfer — ASRM limits referenced

ASRM embryo transfer limitsPolicy references ASRM Table 1 for number of embryos to transfer per attempt; example guidance: 3 embryos for those with a female reproductive system age <35; 4 embryos for those with a female reproductive system age ≥35.

Table 1 reference'Refer to Table 1 below for guidance on number of embryos to transfer per attempt at conception.' (policy note).

FET use conditionFrozen embryo transfer authorization requires number of embryos to transfer meet ASRM Table 1 requirements.

Age thresholds referenced in policy history

Historical age-group adjustmentsPolicy history documents changes to age group criteria and related requirements (e.g., updates in age limits and criteria language during annual reviews).

Authorization, Documentation, and Billing Actions Required of Providers

Prior Authorization

Prior Authorization for Infertility Services

Prior Authorization Required when services are a covered benefit. Authorization is required for the assisted reproductive technology (ART) services listed below when the member's benefit plan includes infertility services and the applicable clinical criteria are met. Services may be denied if prior authorization is not obtained when required.

See code groups for CPT and HCPCS codes that require prior authorization when infertility services are a covered benefit (e.g., 58321, 58322, 58970, 58974, 89250–89291, 89337, 89352–89356, S4011–S4037, etc.).
Providers must submit clinical documentation supporting medical necessity with prior authorization requests (see documentation callout).

Note

Coverage Limited to Members/Enrollees with Infertility Benefits

Coverage is limited to members/enrollees whose benefit plan includes infertility services. Authorization and payment are contingent upon the member's specific benefit contract and any applicable limits, exclusions, or member cost‑share. Providers should verify member eligibility and benefits prior to delivering services.

Policy Background and Scope

Assisted Reproductive Technologies (ART) encompass both clinical treatments and laboratory procedures involving human oocytes, sperm, or embryos with the intent of establishing pregnancy. Examples include in vitro fertilization (IVF), which typically involves ovarian stimulation, oocyte retrieval, sperm preparation, fertilization in the laboratory, and embryo transfer or cryopreservation; as well as techniques such as gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) for patients who decline creation of embryos in vitro or who have specific uterine or transfer-related issues.

Key Definitions

Infertility — Definition

Definition (female reproductive system)Infertility is defined as the inability to conceive or produce conception during a period of one year if under age 35, or during a period of six months if age 35 years or older.

Coverage applicabilityThis infertility definition applies for purposes of the policy when a member/enrollee's benefit plan covers infertility services.

Documentation requirementDocumentation of inability to conceive for the specified time period is required to support medical necessity per the Basic Criteria.

Assisted Reproductive Technologies (ART) — Definition

ART definitionAssisted Reproductive Technologies (ART) encompass clinical treatments and laboratory procedures that include the handling of human oocytes, sperm, or embryos with the intent of establishing pregnancy.

Scope of services

Policy Summary

PayerHealth Net

PolicyAssisted Reproductive Technology (ART)

Policy CodePolicy HNCP MP.55

Change TypeAdded assisted hatchingclarified ICSI guidanceexpanded CPT/HCPCS lists

Effective Date

Next Review Date

Key ActionObtain prior authorization for ART services when the member's benefit includes infertility coverage and medical necessity criteria are met.

SourceLink

On This Page

Examples of modified age thresholdsDocumented historical examples include revisions affecting groups such as ages 38–42 and changes from <39 to <38 in prior history notes.

Policy update contextRevisions and annual reviews note description updates and age limit adjustments without necessarily changing core clinical criteria.

If infertility benefits are not part of the member's plan, services are not covered regardless of clinical criteria.

Benefit limits (e.g., number of cycles, age restrictions, donor/embryo rules) are determined by the member's plan documents.

Documentation Required

Follow Health Plan Administrative Policies and Legal Requirements

Providers must follow Health Plan-level administrative policies and applicable state and federal requirements when requesting authorization, delivering services, and submitting claims. This clinical policy is an evidence‑informed medical necessity guide and does not override the coverage terms in the member's contract.

Effective date for requirements is determined by the Health Plan; posting date may differ from effective date. Legal/regulatory requirements take precedence if discrepancies exist.
Health Plan retains the right to change, amend, or withdraw this clinical policy and its authorization protocols.

Documentation Required

Documentation and Coding Guidance

Documentation must support the basic and treatment‑specific policy criteria and include evidence of board certification/eligibility, clinical evaluation, prior attempts and responses to less invasive therapies where applicable, and any test results cited in the policy.

Include provider credentials (board‑certified or board‑eligible reproductive endocrinologist for those with female reproductive systems; board‑certified/eligible urologist or reproductive endocrinologist for those with male reproductive systems).
Document duration of infertility attempts (12 months generally, or 6 months for those with female reproductive systems age ≥35), prior treatments, and outcomes (e.g., number of IUI attempts, responses to oral agents).
Attach relevant diagnostic test results (semen analyses, hysterosalpingogram, ovarian reserve assessment, prior IVF cycle details) to prior authorization and claim submissions.

Step Therapy

Step Therapy Requirement — Failure of Prior, Less Invasive Therapies

Certain treatments require failure of prior, less invasive therapies (step therapy) before ART such as IVF will be authorized. Providers must document that required prior therapies were attempted and failed unless exceptions in the policy apply.

Examples: For some age groups and indications, authorization for IVF requires documented failure of a specified number of IUI cycles (and/or failure of oral agent cycles such as clomiphene or letrozole) per the policy criteria.
Exceptions include situations listed in the clinical criteria (e.g., certain anatomic barriers, severe male factor infertility, use of donor gametes, HIV discordant couples with sperm washing, or other policy-specified indications).

Billing Rule

Provider Actions — Authorization, Documentation, and Billing

Provider actions summary: verify member benefits and effective dates, obtain prior authorization when required, submit supporting clinical documentation and appropriate CPT/HCPCS codes, and comply with Health Plan administrative policies. Coverage and authorization decisions are subject to the member's coverage documents and applicable law.

Confirm member eligibility and infertility benefit inclusion prior to scheduling services.
Request prior authorization using the Health Plan's designated process and include all required documentation to demonstrate that policy criteria are met.
Use current CPT/HCPCS codes when submitting prior authorization requests and claims; inclusion of a code in the policy does not guarantee coverage.

ART includes procedures such as IVF, IUI, ICSI, GIFT, ZIFT, FET, and cryopreservation when performed for treatment of infertility and meeting policy criteria.

Coverage conditionThese services are considered medically necessary when performed solely for treatment of infertility and when meeting accompanying ART criteria.

ICSI — Definition and use

ICSI definitionIntracytoplasmic Sperm Injection (ICSI) involves injecting the sperm into the egg in the laboratory to fertilize it instead of relying on natural sperm penetration.

Clinical indicationsICSI is appropriate for patients with previously failed fertilization or with sperm concentration and motility too low to expect success with conventional IVF.

Counseling notePatients should be counseled about outcomes and that any increased risk of adverse neonatal outcome associated with ICSI appears to be small.

Assisted Hatching — Definition and brief description

Assisted Hatching definitionAssisted hatching is a laboratory procedure in which the zona pellucida around an embryo (commonly a day‑3 embryo) is mechanically or chemically opened to assist the embryo in hatching and facilitate implantation.

Typical use casesMay improve implantation in selected poor‑prognosis cases (e.g., multiple failed IVF cycles, poor embryo quality, advanced maternal age), though its use remains controversial.

Policy changeAssisted Hatching (CPT 89253) was added to medically necessary procedures in a policy update to accommodate regulatory changes (DMHC APL SB729).

Infertility / recurrent pregnancy loss — Definitions referenced from ASRM committee opinion

ASRM committee definitions referencedThe policy references ASRM Practice Committee opinions for definitions of infertility and recurrent pregnancy loss.

Supporting guidanceCitations include Practice Committee of the American Society for Reproductive Medicine guidance and committee opinions used as reference sources.

Use in policyASRM committee opinions inform clinical definitions and practice recommendations incorporated into the policy criteria.

Access to fertility treatment — Considerations for LGBTQ+ and unmarried persons

Access guidance sourceEthics Committee and ACOG committee opinions referenced support access to fertility treatment for LGBTQ+ and unmarried persons.

Policy acknowledgementThe policy references ASRM and ACOG committee opinions addressing access equity for gays, lesbians, and unmarried individuals.

Coverage applicabilityAccess considerations are noted as referenced ethical and committee opinions; coverage still remains subject to the member's benefit plan terms and applicable laws.