ModifiedHealth-New-EnglandPolicy UM185POL

Infertility Treatment - Medical Policy

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This policy governs Health New England coverage and medical-necessity requirements for infertility services for Commercial and Medicare Advantage members. It applies to medically infertile members seeking treatment to restore normal reproductive capacity, subject to plan benefits, eligibility, prior authorization, and service-specific criteria.

Policy Summary

PayerHealth-New-England

PolicyInfertility Treatment - Medical Policy

Policy CodePolicy UM185POL

Change TypeModified

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionIn-network providers must submit authorization requests using HNE's Infertility Treatment Prior Approval Request Form.

SourceLink

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ModifiedHealth-New-EnglandPolicy UM185POL

Infertility Treatment - Medical Policy

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Policy Summary

PayerHealth-New-England

PolicyInfertility Treatment - Medical Policy

Policy CodePolicy UM185POL

Change TypeModified

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionIn-network providers must submit authorization requests using HNE's Infertility Treatment Prior Approval Request Form.

SourceLink

POLICY UPDATE CHANGES

The policy history records minor criteria changes in July 2026.

General infertility treatment guidelines were added back into the policy section in April 2026.

The policy history records increased storage time for gametes, embryos, or other reproductive tissue to five years for certain indications in May 2025.

CPT 89258 was added to the policy coding guidance without a change to its prior-authorization requirement.

The residency requirement was removed from the policy.

The permitted storage time for gametes, embryos, or other reproductive tissue was increased to five years for certain indications.

CPT code 89258 was added to the policy without changing its prior authorization requirement.

CPT codes 89344 and 89346 were changed to covered services requiring prior authorization.

The policy underwent minor criteria changes.

6 cyclesMaximum IUI cycles with documented ovulation

2 yearsUterine-cavity evaluation validity

5 yearsMaximum storage period for certain indications

<50 ng/mLCotinine threshold for both partners

≥5%Minimum live-birth probability for ART coverage

Infertility Services Coverage Criteria

General Infertility Treatment Criteria

HNE considers infertility treatment medically necessary when both the general criteria and applicable service-specific criteria are met.

ALL of the following

There is a diagnosis of infertility.
No substance-use contraindications
- Both partners do not consume substances against medical advice or without medical indication.
- Both partners do not use illegal substances.
  Serum or urine drug screening may be requested before infertility services are authorized; positive results may result in denial.
If there is a history of substance use
- For tobacco or electronic-cigarette use, urine or serum cotinine is obtained from both partners and is less than 50 ng/mL.
- For alcohol use disorder, either partner with a history of alcohol use has maintained sobriety for at least 6 months.
- For substance use disorder, members and partners in medication-assisted therapy have been enrolled for 1 year, receive MAT with buprenorphine, buprenorphine/naloxone, methadone, or naltrexone, and documentation confirms continued program participation, monitoring, and cognitive behavioral therapy.
Applicable service-specific criteria are also met.

Intrauterine Insemination (IUI) and Sperm Washing

IUI, including sperm washing, is medically necessary when criteria A and B are met.

ALL of the following

A. Uterine cavity evaluation
- Within the past 2 years, sonohysterogram, hysterosalpingogram, or hysteroscopy when indicated, with uterine biopsy results when indicated, confirms at least one patent Fallopian tube, a normal ipsilateral ovary, and a normal endometrial cavity.
B. Confirmation of spontaneous ovulation
- Regular, predictable menstrual cycles at 21–35-day intervals with moliminal symptoms of breast tenderness and bloating.
- Midluteal serum progesterone of ≥3 ng/mL obtained approximately 7 days before expected menses.

Cryopreservation of Sperm and Sperm Collection

Sperm collection, cryopreservation, and storage are medically necessary when any one of the following criteria is met.

ANY ONE of the following

Frozen backup sperm is needed because the member has an unreliable ability to produce adequate or useful sperm on the day of ovulation.
Sperm was recovered through MESA or TESE for a member in active infertility treatment.

Gender-Affirming Fertility Preservation

In addition to the general criteria, cryopreservation of eggs or sperm, including retrieval and up to 5 years of storage or 5 years from the member’s 18th birthday, is medically necessary when all criteria are met.

ALL of the following

Documentation confirms a member with gender dysphoria will undergo covered gender-affirming treatment likely to result in infertility.
Adequate sperm or egg evaluation is completed or documented as needed to establish eligibility.
Documentation confirms that the member and provider(s) discussed the impact of gender-affirming treatment on fertility and family planning.

Donor Sperm

Donor sperm from an accredited sperm bank is medically necessary when the general criteria and an applicable indication are met.

ANY ONE of the following

Severe male-factor infertility, such as sperm concentration below 5 million/mL, cryptozoospermia, or azoospermia.
The biological male has a balanced reciprocal or Robertsonian translocation on karyotype screening and the partner has recurrent pregnancy loss.
Exception: the member meets criteria for preimplantation genetic diagnosis/testing.

Gamete-Intra-Fallopian Transfer (GIFT)

GIFT is medically necessary when both criteria are met.

ALL of the following

The member has one normal patent Fallopian tube.
The member meets IVF criteria.

Intracytoplasmic Sperm Injection (ICSI)

ICSI is medically necessary when any one indication is met.

ANY ONE of the following

Severe male-factor infertility, such as sperm concentration below 5 million/mL, cryptozoospermia, or azoospermia.
Less than 50% fertilization of mature eggs on a previous ICSI attempt.
Sperm was retrieved through MESA or TESE.
Cryopreserved eggs are used.

In-Vitro Fertilization (IVF) Indications

IVF is medically necessary when the general criteria and any one IVF indication are met.

ANY ONE of the following

Documented history of 3 failed medicated IUI cycles when IUI criteria were met.
The female member has bilateral Fallopian-tube absence, excluding prior elective sterilization, or bilateral Fallopian-tube obstruction due to prior tubal disease.
The female member has recurrent pregnancy loss, defined as 2 or more failed pregnancies.
The male member has severe male-factor infertility, such as sperm concentration below 5 million/mL, cryptozoospermia, or azoospermia.
The member is in an approved current IUI cycle with estradiol ≥800 pg/mL and at least 3 follicles larger than 13 mm.

Gamete-Intra-Fallopian Transfer — General Criteria

GIFT is medically necessary when all listed criteria are met.

ALL of the following

The member meets the general infertility-treatment criteria.
The member has one normal patent Fallopian tube.
The member meets IVF criteria.

Intra-Cytoplasmic Sperm Injection — Indications and Exclusion Logic

ICSI is medically necessary for any listed indication; the separate exclusion logic also applies.

ANY ONE of the following

Severe male-factor infertility, including sperm concentration below 5 million/mL, cryptozoospermia, or azoospermia.
Less than 50% fertilization of mature eggs on a previous ICSI attempt.
Sperm was retrieved by MESA or TESE.
Cryopreserved eggs are used.

In-Vitro Fertilization — General Criteria and Indications

IVF requires the general criteria plus at least one listed indication and applicable clinical-guideline requirements.

ALL of the following

ANY ONE IVF indication
- Three failed medicated IUI cycles with IUI criteria met.
- Bilateral Fallopian-tube absence, excluding prior elective sterilization, or bilateral obstruction from prior tubal disease.
- Recurrent pregnancy loss, defined as 2 or more failed pregnancies.
- Severe male-factor infertility.
- Approved IUI cycle with estradiol ≥800 pg/mL and at least 3 follicles >13 mm.

IVF Not Medically Necessary

IVF is not medically necessary in any of the following circumstances.

ANY ONE of the following

The woman is age 44 or older.
Services are requested to treat effects of natural aging or menopause; an FSH level >15 in a member age 40 or older is considered a natural state and is not covered.
IVF using the member’s own eggs is requested after a prior donor-egg cycle.
The probability of achieving a live birth is less than 5%.

Microsurgical Epididymal Sperm Aspiration (MESA)

MESA is medically necessary when the general criteria and the following criterion are met.

ALL of the following

There is congenital absence or congenital obstruction of the vas deferens.
The condition is not obstruction resulting from prior sterilization or sterilization reversal.

Testicular Sperm Extraction (TESE)

TESE is medically necessary when the general criteria and the following condition are documented.

ALL of the following

There is documented nonobstructive azoospermia and spinal-cord injury resulting in inability to ejaculate.

Zygote Intra-Fallopian Transfer (ZIFT)

ZIFT is medically necessary when both criteria are met.

ALL of the following

The member has one normal patent Fallopian tube.
The member meets the IVF criteria.

General ART Eligibility

A member with a uterus/eggs may initiate a covered ART cycle when all requirements are met.

ALL of the following

The member meets the definition of medical infertility, and infertility is not the result of previous sterilization or unsuccessful reversal.
Treatment is likely to result in viable offspring, with a probability greater than 5%.
Documentation, including diagnosis, menopausal status, and prior treatment response and outcomes, confirms that treatment using the female partner’s eggs is expected to result in a live birth.
For premature ovarian failure, premature diminished ovarian reserve, or premature menopause, documentation confirms that absent the diagnosis, fertility would naturally be expected.

Evaluation Requirements

The following evaluations are required before cycle initiation unless an exception is stated.

ALL of the following applicable evaluations

Baseline hormonal blood work, including FSH and estradiol, within the past year.
Rubella testing; nonimmune members must be vaccinated and wait 30 days before requesting treatment.
Annual TSH testing.
HSG or tubal-patency evaluation, unless proceeding directly to IVF.
For direct IVF, uterine-cavity evaluation by HSG, hysteroscopy, sonohysterogram, 3D ultrasound, or HyCoSy every 2 years or after pregnancy loss.

Age-Specific Ovarian Reserve

Members age 40 through 43 must meet all applicable ovarian-reserve requirements.

ALL of the following

Annual clomiphene citrate challenge testing (CCCT).
If 6 months have elapsed since the CCCT, basal FSH and estradiol are obtained before the next fresh IVF cycle.
For IVF coverage, all day-3 or day-10 FSH values are <15 mIU/mL, all day-3 estradiol values are ≤100 pg/mL, and day-10 estradiol is evaluated as specified by the policy.

Biological Male Evaluation

Biological-male evaluation and documentation must meet all applicable requirements.

ALL of the following

Annual semen analysis.
Semen assessment uses the normal fertility threshold defined by WHO.
Medical records from a prior insurer are provided when requested to determine male infertility status.
Medical and reproductive history, including substance use, is submitted.
After vasectomy reversal, 2 post-reversal semen analyses 6 months apart show ≥20 million total motile sperm and ≥3% normal forms.

IVF Response and Embryo Transfer

Prior IVF response and embryo-transfer limits must be met.

ALL of the following

Prior IVF cycles demonstrate adequate response, including at least 3 follicles >12 mm, adequate embryo number and quality for transfer, and adequate fresh and post-wash semen parameters.
A uterine-cavity evaluation by HSG, sonohysterogram, or hysteroscopy was completed within the past 2 years.
Embryo transfers comply with age- and prognosis-specific limits and ASRM guidelines.

IUI coverage is limited to 6 cycles with documented ovulation.

There is no coverage for costs associated with any form of surrogacy, including gestational carriers. Refer to plan benefit documents.

Individuals who are not members, services in which the member is not treated or is not the intended recipient, services resulting from voluntary sterilization or unsuccessful reversal, sperm storage for convenience or backup of a fresh specimen, services when normal embryos are discarded because of gender selection, ART requested solely for noncovered or nonqualifying PGD, services for convenience or lifestyle preference absent medical necessity, treatment to reverse sterilization, MESA/TESE after prior sterilization, supplies available without a physician’s written order, surrogate or gestational-carrier pregnancy services, implantation or other services for a gestational carrier, donor egg with a gestational carrier, donor egg retrieval for donation, donor egg or sperm shipping, endometrial receptivity testing, services for women who are not Rubella immune, voluntary male sterilization, home insemination, and uterine transplants.

Charges for storage of eggs, sperm, or embryos are not covered after completion of an approved series of infertility cycles or more than 1 year after cryopreservation, whichever is shorter.

See the IUI exclusions above: bilateral tubal-factor infertility, recurrent pregnancy loss absent an ovulatory disorder, severe endometriosis, or subsequent IUI after IVF when additional IVF does not meet HNE criteria.

Excluded circumstances include cryopreservation of embryos or eggs for reciprocal IVF and related retrieval, storage, thawing, or re-cryopreservation services outside the covered criteria.

Donor sperm is excluded in the absence of documented male-factor infertility and for genetic sperm defects in a male partner who is not an HNE member.

For women age 44 or older, the need for donor egg or embryo is attributed to normal age-related decline in fertility rather than a disease process.

The source excerpt identifies a separate ICSI not-medically-necessary section, but does not provide additional exclusion details in the available text.

Exclusions include age 44 or older, treatment of natural aging or menopause, FSH >15 in members age 40 or older as a natural state, and IVF using the member’s own eggs after a prior donor-egg cycle. For women age 44 or older, fertility decline is considered age-related regardless of hormonal testing.

ART treatments are not covered for a very poor prognosis, defined as less than a 5% chance of achieving a live birth. The policy also notes that after more than 6 consecutive unsuccessful IVF cycles in women age 40 and older, the chance of live birth is typically below 5%.

Coding Guidance and Clinical Thresholds

HCPCS CodesHCPCSCovered

S4015	Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016	Frozen in vitro fertilization cycle, case rate
S4017	Incomplete cycle, treatment cancelled prior to stimulation, case rate
S4018	Frozen embryo transfer procedure cancelled before transfer, case rate
S4020	In vitro fertilization procedure cancelled before aspiration, case rate
S4021	In vitro fertilization procedure cancelled after aspiration, case rate
S4023	Donor egg cycle, incomplete, case rate
S4025	Donor services for in vitro fertilization (sperm or embryo), case rate
S4026	Procurement of donor sperm from sperm bank (to CPT codes)
S4028	Sperm aspiration from epididymis by means of microsurgery

CPT CodesCPTCovered

58323	Sperm washing for artificial insemination
89253	Assisted embryo hatching, microtechniques (any method)
89258	Cryopreservation; embryos
89259	Cyropreservation of sperm
89344	Storage (per year); reproductive tissue, testicular/ovarian
89346	Storage (per year); oocyte(s)
89354	Thawing of cryopreserved; reproductive tissue, testicular/ovarian
89356	Thawing of cryopreserved; oocytes, each aliquot

Not Covered ServicesneutralNot Covered

No codes listed

CPT code added; prior authorization requirement unchangedCPT

CPT 89258

Covered CPT codes requiring prior authorizationCPTCovered

CPT 89344
CPT 89346

Cotinine

Cotinine requirementUrine or serum cotinine must be obtained from both partners.

ThresholdLess than 50 ng/mL.

Applies toPartners with a history of tobacco use or vaping.

Alcohol use disorder sobriety

Required periodAt least 6 months of sobriety.

Applies toEither partner with a history of alcohol use disorder.

Authorization, Documentation, and Utilization Rules

Prior Authorization

Infertility Prior Approval Form

In-network providers must use HNE's Infertility Treatment Prior Approval Request Form for authorization requests.

Submit through the HNE Provider Site: https://healthnewengland.org/Portals/_default/Shared%20Documents/providers/InfertilityPAdoc.pdf

Prior Authorization

Plan and Medical-Necessity Review

HNE reviews infertility requests against the member's plan benefits, general eligibility criteria, and applicable service-specific medical-necessity criteria. Coverage is available only when both general and service-specific criteria are met.

Verify the member's Evidence of Coverage and plan limitations before requesting or rendering services.
Medical necessity does not by itself guarantee benefit coverage or payment.

Prior Authorization

Policy Background

HNE covers non-experimental infertility services recognized by ASRM or ACOG when the member is medically infertile and the service satisfies applicable plan, eligibility, and medical-necessity requirements. Covered services may include diagnostic evaluation, IUI, IVF, FET, GIFT, ICSI, assisted hatching, donor gametes, sperm retrieval, and cryopreservation.

Policy Definitions

Infertility definition

PopulationOpposite-sex partners under age 35.

Time trying to conceiveAt least 1 year of unprotected intercourse.

DefinitionInability to achieve conception.

Infertility definition

PopulationOpposite-sex partners when the biological female partner trying to conceive is age 35 or older.

Time trying to conceive6 months of unprotected intercourse.

DefinitionInability to achieve conception.

Recent Policy Changes

10/2002original_policy

Original infertility treatment policy issued.

3/2024clarification

Intracytoplasmic sperm injection criteria were clarified.

4/2024removed

The residency requirement was removed from the policy.

Policy Summary

PayerHealth-New-England

PolicyInfertility Treatment - Medical Policy

Policy CodePolicy UM185POL

Change TypeModified

Effective DateDecember 1, 2026

Next Review DateN/A

Key ActionIn-network providers must submit authorization requests using HNE's Infertility Treatment Prior Approval Request Form.

SourceLink

On This Page

Positive urinary midcycle LH surge approximately 14 days before menses.

Follicle rupture documented by transvaginal ultrasound, generally 24–48 hours after the LH surge.

Where applicable, prior IVF response, uterine-cavity evaluation, and embryo-transfer requirements are met.

Annual semen analysis.

Urine or serum cotinine within the month of the requested service for members and partners who acknowledged smoking or vaping within the past year.

A normal semen analysis was obtained 6 months before the infertility-service request.

DocumentationThe sobriety requirement must be satisfied before infertility services are authorized.

Medication-assisted therapy participation

Required participationAt least 1 year enrolled in a medication-assisted therapy program.

Covered medicationsBuprenorphine, buprenorphine/naloxone, methadone, or naltrexone.

Program documentationContinued participation, monitoring, and cognitive behavioral therapy are required.

Midluteal serum progesterone

Progesterone thresholdAt least 3 ng/mL.

TimingApproximately 7 days before expected menses.

PurposeConfirms spontaneous ovulation for IUI criteria.

IUI cycle limit

Maximum coverage6 IUI cycles.

Required documentationOvulation must be documented for each covered cycle.

Related requirementIUI criteria must otherwise be met, including the applicable uterine-cavity evaluation.

Severe oligozoospermia

Sperm concentrationLess than 5 million sperm/mL.

Clinical classificationSevere oligozoospermia is an example of severe male-factor infertility.

Relevant servicesThe threshold appears in donor-sperm and ICSI criteria.

Failed embryo transfers for assisted hatching

Minimum failed transfers2 or more embryo transfers.

Outcome requiredThe transfers occurred without pregnancy.

Service contextAssisted hatching must be part of IVF or FET and another applicable criterion must be met.

Inadequate ovarian response

Egg-retrieval thresholdFewer than 6 eggs retrieved.

Required historyThe threshold must occur in at least 2 IVF treatment cycles.

Clinical useThis documents inadequate ovarian response for donor-egg criteria.

Severe oligozoospermia

Sperm concentrationLess than 5 million sperm/mL.

Additional definitionsSevere male-factor infertility may also include cryptozoospermia or azoospermia.

Relevant serviceThe threshold is included among IVF and ICSI indications.

IUI-to-IVF response

Estradiol thresholdAt least 800 pg/mL.

Follicle responseAt least 3 follicles greater than 13 mm.

Cycle contextThe response must occur during an approved current IUI cycle.

Live-birth prognosis

Minimum probabilityGreater than 5% probability of live birth.

Outcome standardTreatment must be likely to result in viable offspring.

DocumentationClinical history must support that treatment using the female partner's eggs will result in a live birth.

Premature ovarian insufficiency FSH

Age definitionPremature ovarian insufficiency occurs below age 40.

FSH thresholdDay 3 FSH greater than 15 mIU/mL.

Alternative laboratory findingDay 3 estradiol greater than 100 pg/mL without a documented medical reason also meets the laboratory definition.

Ovarian-reserve testing age 40-43

AMHGreater than 1.0 ng/mL.

Antral follicle countGreater than 6.

FSH and estradiolDay 3 FSH less than 15 mIU/mL and day 3 estradiol no higher than 100 pg/mL.

Post-vasectomy-reversal semen analysis

Total motile spermAt least 20 million.

MorphologyAt least 3% normal forms.

Testing scheduleTwo post-reversal semen analyses must be 6 months apart, with a normal analysis 6 months before the request.

Adequate prior IVF response

Follicular responseAt least 3 follicles greater than 12 mm in diameter.

EmbryosAdequate embryo numbers for transfer.

Embryo qualityAdequate embryo quality for transfer, with adequate fresh and post-wash semen parameters.

Storage time

Extended storage periodUp to 5 years for certain medically indicated fertility-preservation indications.

Eggs and embryosMedical fertility preservation outside active treatment may include storage for up to 5 years.

Gender-affirming preservationStorage may be up to 5 years or 5 years from the member's 18th birthday.

Prior Authorization for Infertility Procedure Codes

Prior authorization is required for the listed infertility procedure codes. Code inclusion does not guarantee coverage; benefits are determined under the member's plan document and applicable law.

Step Therapy

One IVF Cycle at a Time

Authorize IVF one cycle at a time so HNE can determine whether the probability of live birth remains adequate using the member's own eggs.

If a cycle does not produce at least one embryo suitable for transfer, another cycle may be considered only when there is a significant change in dosage, protocol, or clinical presentation.

Unsupported block type: prior_auth

Prior Authorization

Prior Authorization for CPT 89344 and 89346

CPT 89344 and 89346 require prior authorization and are covered subject to the member's benefit plan and applicable criteria.

89344: Storage per year; reproductive tissue, testicular/ovarian.
89346: Storage per year; oocyte(s).

Billing Rule

CPT 89258 Added Without PA Change

CPT 89258 was added to the policy as a covered code with no change to its prior-authorization requirement.

89258: Cryopreservation; embryos.
Apply the existing authorization and benefit rules.

Step Therapy

Use Cryopreserved Material First

Use available cryopreserved embryos or eggs before requesting an additional fresh IVF cycle.

Frozen embryos or oocytes must be used before authorization of another fresh cycle.
Thaw-cycle requests must meet the general eligibility criteria at the time of the request.

Step Therapy

IUI After IVF

After IVF, additional IUI cycles are not authorized when further IVF cycles no longer meet HNE's IVF criteria, unless there has been an intervening live birth.

IUI remains limited to six cycles with documented ovulation when IUI criteria are met.

Step Therapy

IUI Before IVF

When IUI criteria are met, IVF generally requires documentation of three failed medicated IUI cycles before authorization.

An exception may apply when another listed IVF indication is met, such as bilateral absence or obstruction of the fallopian tubes, severe male-factor infertility, or an approved IUI cycle with the required estradiol and follicular response.

Step Therapy

Cryopreserved Material Before Fresh Cycle

Before another fresh IVF cycle, document use or evaluation of available cryopreserved embryos or oocytes and the medical necessity of the proposed fresh cycle.

Frozen embryos must be used before additional fresh cycles.
FET requires a normal uterine-cavity evaluation within two years or after a pregnancy or pregnancy loss.

Prior Authorization

Prior Approval Request Form

Submit the completed HNE Infertility Treatment Prior Approval Request Form from the provider site with the authorization request.

Use the HNE Provider Site form for in-network requests.
Include the clinical records needed for review.

Documentation Required

General Eligibility Documentation

Document the infertility diagnosis, relevant substance-use history and screening, required testing, and participation in treatment when applicable.

Both partners must not use substances against medical advice or illegal substances.
For alcohol-use disorder, document at least six months of sobriety; for qualifying substance-use disorder, document one year of medication-assisted treatment participation, monitoring, and CBT.
For recent smoking or vaping, document cotinine testing and required results.

Documentation Required

IUI Clinical Documentation

For IUI, submit documentation that the clinical criteria are met, including a qualifying uterine-cavity and tubal evaluation and confirmation of spontaneous ovulation.

Uterine-cavity evaluation must be by sonohysterogram, hysterosalpingogram, or hysteroscopy when indicated; include biopsy results when indicated.
The evaluation must confirm at least one patent fallopian tube, a normal ipsilateral ovary, and a normal endometrial cavity, generally within the past two years.
Document ovulation by menstrual history, midluteal progesterone ≥3 ng/mL, urinary LH surge, or ultrasound evidence of follicle rupture.
Coverage is limited to six IUI cycles with documented ovulation.

Documentation Required

Fertility Preservation Documentation

For fertility preservation, document active infertility treatment or medical treatment expected to render the member infertile.

For non-active treatment, document the qualifying treatment, such as chemotherapy or radiation, and that infertility is expected to be permanent.
Voluntary sterilization does not qualify.
Preservation for gender-affirming treatment requires documentation of covered treatment likely to cause infertility, adequate evaluation, and discussion of fertility and family planning.

Documentation Required

Donor Gamete Documentation

For donor eggs, document the qualifying medical condition and the member's eligibility for donor-oocyte treatment.

Qualifying conditions include medical loss of egg quantity or quality, congenital or surgical absence of the ovaries, premature ovarian failure or insufficiency, or inadequate response after at least two IVF cycles with fewer than six eggs retrieved.
Donor eggs are generally covered for women under age 44 when criteria are met.
After a donor-egg cycle, further IVF using the member's own eggs is not authorized.

Documentation Required

Gender-Affirming Fertility Preservation Documentation

For fertility preservation associated with gender-affirming treatment, submit documentation that the member has gender dysphoria and will undergo covered treatment likely to result in infertility.

Include adequate sperm or egg evaluation.
Document discussion between the member and provider about treatment effects on fertility and family planning.
Cryopreservation is limited to one cycle and storage is limited to the policy period.

Documentation Required

Infertility and Prognosis History

Submit the infertility diagnosis and prognosis history, including menopausal status and the response to and outcomes of prior infertility treatment.

Documentation must support that treatment using the female partner's eggs is expected to result in a live birth when own-egg treatment is requested.
For premature ovarian failure, diminished reserve, or premature menopause, document that fertility would otherwise naturally be expected.

Documentation Required

Required Baseline Evaluation

Complete and submit the required baseline evaluation before cycle initiation or the requested infertility service.

FSH and estradiol: within the past year.
TSH: yearly.
Semen analysis: yearly.
HSG or other tubal-patency evaluation unless proceeding directly to IVF.
For direct IVF, uterine-cavity evaluation by HSG, hysteroscopy, sonohysterogram, 3D ultrasound, or HyCoSy every two years or after pregnancy loss.

Documentation Required

Cotinine Testing

For members or partners who acknowledge smoking or vaping within the past year, submit urine or serum cotinine obtained within one month of the requested service.

Cotinine must be less than 50 ng/mL for both partners.
A nonsmoking member with an initial negative cotinine test does not require repeat testing.

Documentation Required

Uterine-Cavity Documentation

Document a qualifying uterine-cavity evaluation and its date for infertility treatment authorization.

Acceptable methods include HSG, hysteroscopy, sonohysterogram, 3D ultrasound, or HyCoSy.
Testing is generally valid for two years and must be repeated after a pregnancy or pregnancy loss.

Documentation Required

Age 40–43 Ovarian-Reserve Testing

For members age 40 through 43 seeking fresh IVF, submit annual ovarian-reserve testing and the results required by the policy.

Use the yearly clomiphene citrate challenge test; if six months have elapsed, submit basal FSH and estradiol before the next fresh cycle.
For a documented contraindication to clomiphene or an ovulation disorder, submit same-day basal FSH, estradiol, and AMH plus antral follicle count within one month.
Alternate results must include AMH >1.0 ng/mL, AFC >6, day-3 FSH <15 mIU/mL, and day-3 estradiol ≤100 pg/mL.

Documentation Required

Post-Reversal Male-Factor Records

After vasectomy reversal, submit two post-reversal semen analyses six months apart and the additional baseline analysis required by the policy.

Each post-reversal analysis must show ≥20 million total motile sperm and ≥3% normal forms.
Submit a normal semen analysis from six months before the infertility service request.

Documentation Required

Prior IVF-Cycle Documentation

For a prior IVF cycle, submit records documenting follicular response, embryo development and quality, semen parameters, and cycle outcome.

Prior cycles must show at least three follicles >12 mm and adequate embryo numbers and quality for transfer.
Include adequate fresh and post-wash semen parameters.
Document the outcome and any embryos available for freezing or transfer.

Documentation Required

Submit Clinical Evidence for Prior Authorization

The treating physician or primary care provider must submit clinical evidence showing that the patient meets HNE's criteria for the requested treatment, testing, or procedure.

Without the required documentation, HNE cannot properly review the prior-authorization request.
Medical-necessity determination does not override the member's benefit exclusions or limitations.

Denial Risk

Substance-Use Contraindications

Infertility treatment may be denied when substance-use contraindications are present or required treatment participation is not documented.

Positive serum or urine drug screening may result in denial.
Illegal substance use or substance use without medical indication is disqualifying.
Required sobriety, cotinine, or medication-assisted-treatment participation and monitoring must be documented.

Denial Risk

IUI Exclusion Criteria

IUI is not medically necessary for bilateral tubal-factor infertility, recurrent pregnancy loss absent an ovulatory disorder, or severe endometriosis.

Recurrent pregnancy loss means two or more failed pregnancies absent an ovulatory disorder.
Confirm that the member meets the tubal, ovarian, uterine-cavity, and ovulation requirements before requesting IUI.

Denial Risk

Assisted Hatching Exclusions

Assisted hatching is not medically necessary when PGD is being performed or when the IVF cycle will not lead to embryo transfer.

PGD includes opening the zona pellucida.
Document that assisted hatching is part of IVF or FET and that a qualifying indication is present.

Denial Risk

Cryopreservation Exclusions

Cryopreservation is not medically necessary when the cycle will not lead to embryo transfer or for excluded preservation circumstances.

Excluded circumstances include preservation of embryos or eggs for reciprocal IVF.
Convenience or backup storage without a qualifying indication is not covered.
Surrogacy and gestational-carrier costs are excluded.

Denial Risk

Donor Sperm Exclusions

Donor sperm is not medically necessary without documented male-factor infertility or the specified qualifying genetic circumstances.

Qualifying severe male factor includes concentration <5 million/mL, cryptozoospermia, or azoospermia.
A qualifying balanced reciprocal or Robertsonian translocation requires appropriate karyotype findings and recurrent pregnancy loss in the partner.
Donor sperm may also qualify when the member meets PGT criteria.

Denial Risk

Post-Donor-Egg Treatment Restriction

After a donor-egg cycle, further IVF cycles using the member's own eggs are not authorized.

Plan treatment sequencing before proceeding with donor eggs.

Denial Risk

Surrogacy Exclusion

HNE does not cover costs associated with achieving pregnancy through a surrogate or gestational carrier.

Excluded services include implantation, embryo transfer, pregnancy-related costs, and cryopreservation provided for or involving a gestational carrier.
The gestational carrier need not be an HNE member for the exclusion to apply.

Denial Risk

Eligibility and Medical-Necessity Failure

Requests may be denied when policy criteria, recipient requirements, or member eligibility requirements are not met.

The patient must be an HNE member and the intended recipient of the infertility service.
The requested service must meet both general and service-specific criteria.
Verify plan benefits because medical necessity alone does not establish coverage.

Denial Risk

Sterilization-Related Infertility

Infertility services are excluded when requested because of prior voluntary sterilization or an unsuccessful sterilization-reversal procedure.

This exclusion includes consultations, laboratory and radiology studies, infertility drugs, ART cycles, and related services.
MESA or TESE is not covered after prior sterilization.

Denial Risk

Poor Prognosis or Inadequate Outcome Probability

ART is not covered when the probability of achieving a live birth is 5% or less or when the policy's prognosis requirements are not met.

Treatment must be expected to result in viable offspring with a probability greater than 5%.
After more than six consecutive unsuccessful IVF cycles in women age 40 or older, the chance is typically below 5%.
Submit clinical history and prior outcomes supporting the prognosis.

Denial Risk

Age, Menopause, or Prior Donor-Egg Cycle

Own-egg IVF is not medically necessary for members age 44 or older, members who are menopausal or experiencing natural age-related infertility, or members with a prior donor-egg cycle.

For members age 40 or older, an FSH >15 is treated as natural infertility and excludes further infertility services, subject to the policy's limited frozen-embryo-transfer provision.
Members age 44 or older may not receive own-egg IVF regardless of hormonal testing.

Denial Risk

Gestational-Carrier Services

Services for a gestational carrier are excluded, including pregnancy, implantation, embryo transfer, and related cryopreservation or pregnancy costs.

Donor egg used with a gestational carrier is excluded even when the carrier is an HNE member.

Denial Risk

Excluded Purposes and Services

HNE excludes ART and infertility services requested solely for noncovered purposes or personal preference.

Gender selection involving discarding normal embryos is excluded.
ART requested solely for PGD is excluded when PGD is not covered or its criteria are not met.
Lifestyle, convenience, personal, or religious preference without medical necessity is not covered.
Also excluded: home insemination, uterine transplants, ovulation test kits available without a physician's order, and endometrial receptivity testing.

Denial Risk

Donor and Storage Charges

Do not bill HNE for excluded donor, transport, convenience-banking, or storage charges.

Excluded charges include sperm storage for convenience or backup, storage after the approved cycle series or beyond one year after cryopreservation, whichever is shorter.
Egg-donor payment, identification, legal services, selection, purchase, and transportation are excluded.
Purchase and transportation of frozen donor eggs or embryos and shipping of donor egg or donor sperm are excluded.
Medical removal of an egg for donation for a plan member is not excluded by the donor-fee provision.

Denial Risk

Rubella Nonimmunity

Members who are not Rubella immune must be vaccinated and wait 30 days before requesting infertility treatment.

Submit Rubella testing and vaccination documentation with the authorization request.

Denial Risk

Male Sterilization or Reversal

Voluntary male sterilization ends coverage for IVF, ICSI, and donor sperm based on male factor or unexplained infertility; an abnormal post-reversal semen analysis ends eligibility for infertility services.

Chemical or procedural voluntary sterilization is included.
Document reversal outcomes and required semen analyses before requesting treatment.

Step Therapy

Use of Cryopreserved Material Before Fresh Cycles

Before requesting a fresh IVF cycle, document use of eligible frozen embryos or oocytes and complete the evaluation required for FET or thaw-cycle treatment.

Frozen material must be used before an additional fresh cycle.
FET requires a normal uterine-cavity evaluation within two years or after pregnancy or pregnancy loss.
Thaw-cycle authorization requires the general eligibility criteria to be met at the time of the request.

Infertility definition

PopulationBiological female under age 35 without an opposite-sex partner.

Required treatment attemptsAt least 6 trials of medically supervised artificial insemination.

DefinitionInability to achieve conception after those trials.

Infertility definition

PopulationBiological female age 35 or older without an opposite-sex partner.

Required treatment attemptsAt least 3 trials of medically supervised artificial insemination.

DefinitionInability to achieve conception after those trials.

Biological female

Chromosomal descriptionA member with two X chromosomes or no Y chromosome.

Policy terminologyThe term describes reproductive capacity rather than gender identity.

Inclusion statementThe term includes members with gender identities other than female and does not exclude other gender identities or expressions.

Biological male

Chromosomal descriptionA member with XY chromosomes.

Policy terminologyThe term describes reproductive capacity rather than gender identity.

Inclusion statementThe term includes members with gender identities other than male and does not exclude other gender identities or expressions.

Severe male-factor infertility

CryptozoospermiaSperm found only after centrifugation.

AzoospermiaComplete absence of sperm in the ejaculate.

Clinical categoryBoth are examples of severe male-factor infertility.

Premature ovarian insufficiency

Age definitionOccurs below age 40.

FSH findingDay 3 FSH greater than 15 mIU/mL.

Estradiol findingDay 3 estradiol greater than 100 pg/mL without a documented medical reason, such as an ovarian cyst.

Adequate prognosis

Adequate prognosisTreatment is considered likely to result in viable offspring.

Live-birth probabilityGreater than 5%.

Cycle-initiation standardThe probability requirement must be met before a covered ART cycle is initiated.

5/2025revised_and_added

Storage time for gametes, embryos, or other reproductive tissue was increased to five years for certain indications, CPT 89258 was added without changing its prior-authorization requirement, and CPT 89344 and 89346 were changed to covered services requiring prior authorization.

4/2026added

General infertility treatment guidelines were added back into the policy section.

07/2026revisedLatest

The policy underwent minor criteria changes.