CurrentHighmark PennsylvaniaPolicy N/A

In Vitro Fertilization (IVF) coverage criteria

Form and criteria governing prior authorization and medical necessity determination for IVF services for Highmark/Blue Cross Blue Shield Delaware members; affects providers requesting IVF coverage.

Policy Summary

PayerHighmark Pennsylvania

PolicyIn Vitro Fertilization (IVF) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed IVF questionnaire and supporting clinical documentation to Claims Review/Medical Management for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13distinct listed clinical indications for IVF

>=3minimum failed ovulation induction cycles before IVF for unexplained infertility

AMH < 1.0threshold for diminished ovarian reserve

<5Mtotal motile sperm threshold for male factor indication

Coverage Criteria for In Vitro Fertilization (IVF)

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The policy does not list any standalone exclusions beyond the specific coverage indications. However, prior authorization is required and approval depends on receipt of the completed Request for IVF Coverage questionnaire plus supporting clinical documentation. Failure to submit the completed authorization form and requested records to Medical Management and Policy (fax: 800.670.4862 or 888.236.6321) may result in no prior authorization determination and denial of coverage.

This document does not include any explicit statements that services are "not medically necessary." The guidance is framed as a set of criteria and an authorization process rather than affirmative noncoverage language.

Clinical Thresholds and Coding-relevant Criteria

Clinical thresholds

Anti-Müllerian Hormone (AMH)AMH < 1.0

Early follicular FSHEarly follicular FSH ≥ 10.0

Antral follicle count (AFC)Persistent bilateral AFC ≤ 5 (both ovaries, consistent over 2–3 determinations)

Total motile spermTotal motile sperm < 5 million

Sperm morphologyNormal morphology < 5% by strict Kruger criteria

Failed ovulation induction (unexplained infertility)No successful conception after ≥ 3 properly managed ovulation induction cycles, with or without IUI

Provider Submission & Prior Authorization Requirements

Prior Authorization

Prior authorization required

Prior authorization is required. Providers must submit the completed Request for IVF Coverage questionnaire and supporting clinical documentation to Claims Review/Medical Management for an IVF coverage determination.

Step Therapy

Prior treatment expectations before IVF

Documented prior treatment trials are expected for certain indications: failed ovulation induction with oral agents or properly managed ovulation induction ± IUI cycles are prerequisites before IVF when applicable.

PCOS: ovulation induction that does not produce follicular growth with oral agents, >2 dominant follicles routinely with oral agents, or >3 failed ovulation induction cycles.
Unexplained infertility: no successful conception after 3 properly managed ovulation induction cycles, with or without IUI.

Documentation Required

Required submission materials (IVF questionnaire)

Submit a completed Request for IVF Coverage questionnaire including physician and patient identifiers, brief patient history, infertility work‑up and test results, proposed treatment, signature, and any supporting clinical documentation to Medical Management for prior authorization.

Physician name and address, patient name, Highmark BCBS DE ID#, current date, Blue Cross Blue Shield Provider ID# and signature.
Infertility work‑up and treatments/medications/surgery to date — list tests and results, cause of infertility, and proposed treatment.

Denial Risk

Submission requirement and denial risk

Failure to fax the completed IVF questionnaire and supporting clinical documentation to the Medical Management and Policy Department may result in no prior authorization determination and could preclude approval.

Fax to Medical Management and Policy Department for Prior Authorization: 800.670.4862 (Delaware) or 888.236.6321.

Background and Rationale

In vitro fertilization (IVF) is used across a range of infertility etiologies. Indications addressed by the policy include advanced maternal age, diminished ovarian reserve (for example, AMH < 1.0, elevated early follicular FSH, or persistently low antral follicle counts), significant male factor infertility (such as very low total motile sperm or poor morphology), anatomic problems like bilateral tubal disease or severe pelvic adhesions, situations requiring a gestational carrier (for example after hysterectomy), couples with balanced translocations or high genetic risk who will pursue PGT, fertility preservation prior to gonadotoxic therapy, and unexplained infertility after failed ovulation induction/IUI. Use of IVF for these indications is contingent on meeting the clinical criteria and completing the required prior authorization process.

Definitions and Diagnostic Thresholds

Diminished ovarian reserve — definition

DefinitionDiminished ovarian reserve is defined by any one of: AMH < 1.0; early follicular FSH ≥ 10.0; or persistent bilateral antral follicle count ≤ 5 over 2–3 determinations.

AMH thresholdAMH < 1.0

FSH thresholdEarly follicular FSH ≥ 10.0

AFC requirementPersistent bilateral AFC ≤ 5 (both ovaries consistent over 2–3 determinations)

Male factor infertility — definition

DefinitionMale factor infertility is defined as ejaculated sperm unsuitable for IUI, including total motile sperm < 5 million or normal morphology < 5% by strict Kruger criteria.

Low motile count< 5 million total motile sperm (unsuitable for IUI)

Poor morphology< 5% normal morphology by strict Kruger criteria

Sperm retrievable only by special methodsSperm obtainable only from urine (retrograde ejaculation), electroejaculation, epididymal aspiration, or testicular biopsy

Recurrent pregnancy loss — definition

DefinitionRecurrent pregnancy loss is defined as ≥ 3 clinical pregnancy losses (confirmed by ultrasound) if maternal age < 35 with negative evaluation, or ≥ 2 clinical pregnancy losses if maternal age ≥ 35 with negative evaluation.

Age < 35≥ 3 clinical pregnancy losses (pregnancy confirmed by ultrasound) with negative evaluation

Age ≥ 35≥ 2 clinical pregnancy losses (pregnancy confirmed by ultrasound) with negative evaluation