Highmark Blueshield Neny IVF Coverage Prior Auth

IVF Coverage Criteria

Advanced Maternal Age

Covered when ALL of the following are met

Advanced Maternal Age: Female partner ≥ age 35 after attempting conception for ≥ 6 monthsage ≥35; attempt conception ≥6 months

Infertility with Diminished Ovarian Reserve

Covered when ANY of the following laboratory/imaging criteria are met

Diminished Ovarian Reserve: AMH < 1.0AMH < 1.0

Diminished Ovarian Reserve: Early follicular FSH ≥ 10.0FSH ≥ 10.0

Diminished Ovarian Reserve: Persistent bilateral antral follicle count (AFC) ≤ 5 total for both ovaries over 2-3 determinationsAFC ≤ 5 (total, confirmed over 2-3 determinations)

Total for both ovaries consistent over 2-3 determinations

Male factor infertility

Covered when ANY of the following are present

Male factor - poor sperm for IUI: Ejaculated sperm unsuitable for IUI (poor count, motility, or morphology): < 5 million total motile sperm or < 5% normal morphology by strict Kruger criteria<5 million total motile sperm; <5% normal morphology

Male factor - sperm obtainable only by specialized retrieval: Partner sperm only obtainable from urine (retrograde ejaculation), via electroejaculation, or via epididymal aspiration/testicular biopsyn/a

Tubal disease

Covered when ANY of the following are present

Tubal disease: Idiopathic or iatrogenic irreparable bilateral tubal occlusionn/a

Tubal disease: Prior bilateral salpingectomyn/a

Tubal disease: Bilateral hydrosalpinxn/a

Tubal disease: Severely abnormal tubes based on laparoscopic assessment

Pelvic adhesions / Prior laparotomy

Covered when ONE of the following is met

Pelvic adhesions: Severe adhesive disease diagnosed by laparoscopyn/a

Prior laparotomy: Laparoscopic evaluation is contraindicated or severe pelvic adhesions diagnosed by laparoscopyn/a

PCOS

Covered when ANY of the following apply

PCOS - no follicular growth with oral agents: Ovulation induction does not produce follicular growth with oral agents (e.g., clomiphene, letrozole)n/a

PCOS - excessive multifollicular response: Oral agent therapy routinely results in > 2 dominant follicles>2 dominant follicles

PCOS - failure to conceive after cycles: > 3 ovulation induction cycles fail to result in conception>3 failed OI cycles

Recurrent pregnancy loss

Covered when ONE of the following is met and evaluation for underlying cause is negative

Recurrent loss (<35): ≥3 clinical pregnancy losses (pregnancy confirmed by ultrasound) if maternal age < 35 and evaluation for underlying cause is negative≥3 losses

Recurrent loss (≥35): ≥2 clinical pregnancy losses (pregnancy confirmed by ultrasound) if maternal age ≥ 35 and evaluation for underlying cause is negative≥2 losses

Genetic indications for PGT

Covered when ONE of the following genetic risks are present

Balanced translocation: Balanced chromosome translocation in either partner where PGT-SR would be carried outn/a

High genetic risk: Dominant disorder in either partner or the same recessive disorder in both partners where PGT-M would be carried outn/a

Fertility preservation

Covered when ALL of the following are met

Fertility preservation: Embryo creation or oocyte cryopreservation in setting of cancer or other diseases where treatments are toxic to ovaries and oocytesdocumented need for gonadotoxic therapy

Use of gestational carrier

Covered when ANY of the following are present

Gestational carrier - prior hysterectomy: Prior hysterectomyn/a

Gestational carrier - uterine anomaly: Severe uterine anomalyn/a

Gestational carrier - pregnancy contraindicated: Pregnancy is medically contraindicatedn/a

Unexplained infertility

Covered when ALL of the following are met

Unexplained infertility after failed OI/IUI: No successful conception after 3 properly managed ovulation induction cycles, with or without intrauterine insemination by an OBGYN or an REI3 properly managed OI cycles

This policy sets specific clinical criteria under which in vitro fertilization (IVF) and related services are considered medically necessary and eligible for coverage. Providers must submit a completed IVF coverage questionnaire and supporting clinical documentation to Claims Review/Medical Management for prior authorization; fax numbers for Delaware submissions are 800.670.4862 or 888.236.6321. Failure to submit the completed form and supporting documentation may result in no coverage determination.

Covered indications include (but are not limited to) advanced maternal age (female partner ≥35 after attempting conception for ≥6 months), diminished ovarian reserve (for example AMH < 1.0, early follicular FSH ≥ 10.0, or persistent bilateral AFC ≤ 5 over 2–3 determinations), male factor infertility (e.g., < 5 million total motile sperm or < 5% normal morphology by strict Kruger criteria or sperm obtainable only by specialized retrieval), tubal disease, pelvic adhesions or prior laparotomy precluding less invasive treatment, PCOS refractory to oral ovulation induction or after >3 failed OI cycles, recurrent pregnancy loss (≥3 losses if <35; ≥2 if ≥35, after negative evaluation), genetic indications for PGT, fertility preservation for gonadotoxic therapy, use of a gestational carrier when indicated, and unexplained infertility after failure of 3 properly managed ovulation induction cycles with or without IUI.

When criteria specify trial of ovulation induction or other step therapy (for example for PCOS or unexplained infertility), documentation should show the number and outcome of properly managed cycles. The form identifier used in this packet is CLM-140.

Key clinical thresholds referenced in the criteria include: AMH < 1.0, early follicular FSH ≥ 10.0, persistent bilateral AFC ≤ 5, total motile sperm < 5 million, strict Kruger morphology < 5%, and failure to conceive after 3 properly managed ovulation induction cycles (with or without IUI).

Recurrent pregnancy loss is defined for coverage purposes as ≥3 clinical pregnancy losses confirmed by ultrasound for members <35 years old, or ≥2 losses for members ≥35, after a negative evaluation for an underlying cause.

Form Identifiers & Clinical Thresholds

Form identifiersmixed

CLM-140

Form identifier

Clinical thresholds — key values

Anti-Müllerian Hormone (AMH)AMH < 1.0

Early follicular FSHFSH ≥ 10.0

Bilateral antral follicle count (AFC)Persistent bilateral AFC ≤ 5 (total for both ovaries consistent over 2–3 determinations)

Total motile sperm< 5 million total motile sperm

Sperm morphology (strict Kruger)< 5% normal morphology by strict Kruger criteria

Recurrent clinical pregnancy loss≥ 3 losses if maternal age < 35; ≥ 2 losses if maternal age ≥ 35 (clinical pregnancy confirmed by ultrasound)

Prior Authorization & Submission Instructions

Prior Authorization

Prior authorization required

Prior authorization is required by submitting the completed IVF coverage questionnaire and supporting clinical documentation to Claims Review/Medical Management for a coverage determination.

Step Therapy

Failure of ovulation induction required in some cases

For members with PCOS or unexplained infertility, IVF is considered only after failure of specified ovulation induction (OI) attempts as described in the criteria (e.g., >3 failed OI cycles for PCOS or no conception after 3 properly managed OI cycles with or without IUI for unexplained infertility).

PCOS: >3 ovulation induction cycles fail to result in conception or no follicular growth with oral agents or excessive multifollicular response (>2 dominant follicles).
Unexplained infertility: no successful conception after 3 properly managed OI cycles, with or without IUI, by an OBGYN or REI.

Background

This background summarizes the clinical indications under which IVF and associated procedures (including preimplantation genetic testing and fertility preservation) are considered appropriate. Indications include advanced maternal age, diminished ovarian reserve, male factor infertility, tubal disease, significant pelvic adhesions or prior laparotomy that precludes corrective surgery or laparoscopy, PCOS not responsive to oral ovulation induction (or with excessive multifollicular response), recurrent pregnancy loss after negative evaluation, balanced chromosomal translocation or other high genetic risk scenarios warranting PGT, embryo or oocyte cryopreservation when gonadotoxic therapy is planned, need for a gestational carrier (e.g., prior hysterectomy or severe uterine anomaly), and unexplained infertility after failure of properly managed ovulation induction/IUI cycles.

Providers seeking coverage determinations must document the specific clinical findings and prior treatments that satisfy the applicable criteria and submit them with the prior authorization questionnaire to Medical Management for review.

Key Definitions

Advanced Maternal Age

DefinitionFemale partner ≥ age 35 after attempting conception for ≥ 6 months.

Coverage logicCovered when ALL of the following are met (age and duration of attempted conception).

Source noteUsed as an indication for IVF when criteria satisfied per policy.

Diminished Ovarian Reserve — laboratory/imaging thresholds

AMH thresholdAMH < 1.0.

Early follicular FSHEarly follicular FSH ≥ 10.0.

Bilateral AFCPersistent bilateral AFC ≤ 5 (total for both ovaries consistent over 2–3 determinations).

OpenPayer

In Vitro Fertilization (IVF) coverage criteria for Delaware members

IVF Coverage Criteria

Form Identifiers & Clinical Thresholds

Prior Authorization & Submission Instructions

Background

Key Definitions