In Vitro Fertilization (IVF) Coverage Criteria
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Defines medical indications and prior authorization information for IVF coverage for Highmark BlueCross BlueShield Delaware members; intended for providers requesting authorization and documenting infertility diagnoses and prior treatments.
No material clinical or coverage changes in this revision.
IVF Coverage Criteria
Covered indications for IVF
Covered when ONE of the following indications is met (each line describes a distinct qualifying indication):
Chunk 8 specifies differing counts by maternal age.
The source document does not include an explicit list of cosmetic or nonmedical exclusions. The IVF request form and accompanying materials ask for clinical history and supporting documentation for prior authorization but do not state any specific exclusions for cosmetic or nonmedical indications.
The document contains no explicit statements labeling services or scenarios as "not medically necessary." The form focuses on collecting clinical history, infertility work-up, tests, proposed treatment, and supporting documentation for prior authorization without providing named "not medically necessary" language.
Codes, Thresholds, and Numeric Criteria
| affected codes | Placeholder - document references prior authorization for IVF but does not list specific CPT/HCPCS/ICD codes. |
Prior Authorization & Submission Requirements
Prior authorization required for IVF
Prior authorization is required for In Vitro Fertilization. Providers must fax the completed IVF questionnaire and all supporting clinical documentation to the Medical Management and Policy Department for review prior to services.
Required prior failed cycles for some indications
Certain indications require documented prior failed ovulation induction cycles before IVF is covered: for PCOS, more than 3 ovulation induction cycles that fail to result in conception (or settings where oral agents routinely produce >2 dominant follicles); for unexplained infertility, no successful conception after 3 properly managed ovulation induction cycles, with or without IUI.
- PCOS: >3 failed ovulation induction cycles (or >2 dominant follicles with oral agents).
- Unexplained infertility: no conception after 3 properly managed ovulation induction cycles, with or without IUI.
Required prior authorization submission materials
Providers must submit a completed IVF request questionnaire including brief patient history, infertility work‑up and treatments, medications, surgeries, tests and results, the specified cause of infertility, proposed treatment, and the provider signature; supporting clinical documentation should be faxed to the Medical Management and Policy Department.
- Brief patient history
- Infertility work‑up and treatments, medications, surgeries
- Tests and results
- Cause of infertility and proposed treatment
- Provider signature and contact information
Submit completed questionnaire and documentation via specified fax
Failure to fax the completed IVF questionnaire and supporting clinical documentation to the Medical Management and Policy Department via the listed fax numbers may prevent prior authorization and result in denial.
- Fax numbers for submission: 800.670.4862 (Delaware) or 888.236.6321
Clinical Background
Infertility is multifactorial and may reflect female factors such as advanced maternal age or diminished ovarian reserve, male factors affecting sperm count, motility, or morphology, or anatomic conditions such as tubal disease or severe pelvic adhesions. Prior pelvic surgery (for example prior laparotomy or salpingectomy) can affect fertility by producing adhesions or irreparable tubal damage. Anovulation from conditions like polycystic ovary syndrome and assisted-reproduction‑relevant genetic or uterine conditions (for example chromosomal rearrangements or uterine anomalies requiring a gestational carrier) are also recognized contributors. The form requests a brief patient history and infertility work-up and tests so the submitted documentation can demonstrate which of these clinical causes applies for prior authorization review.
Key Definitions
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