CurrentMass General Brigham Health PlanPolicy 029

Infertility Services/Assisted Reproductive Services

Defines Mass General Brigham Health Plan clinical coverage criteria, eligibility, covered procedures, exclusions, and service-specific requirements for assisted reproductive services (AI/IUI, IVF, ICSI, donor gametes, cryopreservation, MESA/TESE, etc.) for applicable commercial, Medicare Advantage, One Care/SCO, and ACO members. Part 1 of 3; only content in this part is summarized.

Policy Summary

PayerMass General Brigham Health Plan

PolicyInfertility Services/Assisted Reproductive Services

Policy CodePolicy 029

Change TypeMultiple ad hoc revisions and additions (2024-2026)

Effective Date

Next Review Date

Key ActionPrior authorization is required for Medicare Advantage, One Care/SCO, and Commercial/Qualified Health Plan members per plan; IVF medications are covered only if IVF or medicated IUI services have been approved.

SourceLink

POLICY UPDATE CHANGES

April 2026: Ad hoc review. Reformatted policy. Clarified criteria hierarchy in One Care and SCO section. Updated summary of evidence and references.

January 2026: Ad hoc review. Updated prior authorization table and table of contents and added variation for One Care and SCO members.

September 2025: Added coverage for cryopreservation of ovarian tissue for members undergoing gonadotoxic therapy; updated FET criteria and code list; PA table updated.

July 2025: Added exclusion for reciprocal IVF when IVF criteria are not met; removed references to coverage for members without a diagnosis of infertility or not undergoing treatment likely to result in infertility.

March 2024: Multiple substantive clarifications to eligibility, ovarian reserve timing, FET criteria, IVF cycle limits removed, donor egg language reordered, added urology consult language for ICSI.

MultipleCovered Procedures Listed

2 yearsCryopreservation Storage Limit

1IVF cycles approved at a time

1MESA/TESE lifetime limit

multipleProcedure codes listed

state_regulationGuiding regulation

Coverage Summary & Scope

Policy 029 (Medical Necessity Guidelines: Infertility Services/Assisted Reproductive Services) is CURRENT and defines Mass General Brigham Health Plan clinical coverage criteria used to determine medical appropriateness for assisted reproductive services for members diagnosed with infertility. It applies to applicable Commercial, Medicare Advantage, One Care/SCO, and ACO members, with plan-specific variations and prior authorization requirements noted per product. The scope summary indicates this is Part 1 of 3 and only the content in this part is summarized here.

The policy explicitly aligns coverage and clinical criteria with Massachusetts regulation 211 CMR 37.00 (Division of Insurance infertility benefits) and permits using standards from professional societies — specifically ASRM, ACOG, and SART — as the basis for clinical guidelines. Coverage of IVF medications is conditional: IVF medications are provided only if the IVF or medicated IUI services have been approved by the plan.

Key thresholds and limits (compact)

Infertility diagnostic timeframesUnable to conceive after 1 year if <35; after 6 months if ≥35 (includes time attempting to conceive prior to miscarriage).

Cryopreservation storage limitCryopreservation of eggs/embryos, ovarian tissue, and sperm covered with storage up to 2 years from retrieval when authorized.

IVF cycles approved at a timeNo more than one IVF cycle may be approved at a time.

MESA/TESE lifetime limitMESA and TESE are covered one time per lifetime (one MESA per lifetime; one TESE per lifetime).

Live birth probability minimumThere must be >5% probability that the requested treatment will result in a live birth using the member's own eggs (or >5% for cryopreserved sperm use).

Donor age limit (donor eggs)Anonymous or designated egg donors must be ≤35 years, or 36–39 if normal ovarian reserve; donors ≥40 are not appropriate.

IUI→IVF conversion thresholdsConversion from IUI to IVF covered when current IUI cycle estradiol ≥800 pg/mL AND the cycle produced ≥5 follicles >13 mm diameter.

Clinical Eligibility and Medical Necessity

General Eligibility Coverage Criteria for Treatment of Infertility

Covered when ALL of the following are met:

General Eligibility

1. Fertility expectation: The member must otherwise be an individual in whom fertility would be expected.
2. Demonstration of infertility
- 2a: timed attempt: Regularly attempted to conceive with a partner who has testes/sperm but unable to conceive during a 1-year period if <35 or 6 months if ≥35 (includes time attempting to conceive prior to miscarriage).1 year (<35) or 6 months (≥35)

Procedure Codes

Informational procedure codes listedmixed

89389	Unlisted reproductive medicine laboratory procedures; includes: cryopreservation: immature oocytes, ovarian reproductive tissue.
S4011	In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development.
S4013	Complete cycle, gamete intrafallopian transfer (GIFT), case rate.
S4014	Complete cycle, zygote intrafallopian transfer (ZIFT), case rate.
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.

1–10 of 22

1/3

Informational codes mentionedmixed

89389	Unlisted reproductive medicine laboratory procedures; includes: cryopreservation: immature oocytes, ovarian reproductive tissue.
S4011	In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development.

Prior Authorization, Documentation & Billing Rules

Prior Authorization

Prior authorization required

Prior authorization is required for Medicare Advantage, One Care/SCO, and Commercial/Qualified Health Plan members. IVF medications are covered only when IVF or a medicated IUI service has been approved.

Documentation Required

Submit semen analyses and cycle details

Submit a semen analysis from within the past year. If a sample is abnormal, obtain and submit a second semen analysis within the past year. For cycle documentation, providers must submit all prior treatment and cycle details, including pre- and post-wash semen analyses.

Required semen analyses: initial sample within past year; second sample within past year if abnormal
Include pre-wash and post-wash semen analyses

Background & Evidence

Background: the purpose of this document is to describe the clinical coverage criteria Mass General Brigham Health Plan uses to determine medical appropriateness for assisted reproductive services for members diagnosed with infertility. It does not address treatment of the underlying medical condition causing infertility and notes infertility timeframes consistent with regulation.

The policy is explicitly aligned with Massachusetts regulation 211 CMR 37.00 and expects services to follow guidance and standards from professional societies, including the American Society for Reproductive Medicine (ASRM), the American College of Obstetricians and Gynecologists (ACOG), and the Society for Assisted Reproductive Technology (SART) as acceptable bases for clinical guidelines.

IVF medication coverage is dependent on prior authorization for the related assisted reproductive service: IVF medications are covered only when IVF or medicated IUI services have been approved. Note: this document represents Part 1 of 3 of the policy; it summarizes only the first part of the policy content.

Evidence summary

Definitions & key clinical thresholds

Policy Revision Timeline

March 2024clarified

Multiple substantive clarifications to eligibility criteria, ovarian reserve timing, FET criteria, removal of IVF cycle limits, donor egg language reordered, and added urology consult language for ICSI per March 2024 ad hoc review.

July 2025revised

Added exclusion for reciprocal IVF when IVF criteria are not met and removed references to coverage for members without a diagnosis of infertility or not undergoing treatment likely to result in infertility (July 2025 annual review).

September 2025added

Coverage for cryopreservation of ovarian tissue for members undergoing gonadotoxic therapy added; FET criteria and code list updated; prior authorization table updated (September 2025 ad hoc review).

Policy Summary

PayerMass General Brigham Health Plan

PolicyInfertility Services/Assisted Reproductive Services

Policy CodePolicy 029

Change TypeMultiple ad hoc revisions and additions (2024-2026)

Effective Date

Next Review Date

SourceLink

On This Page

2b: no sperm exposure:

For members with uteri/ovaries without exposure to sperm: unable to conceive after completion of six AI/IUI cycles with donor sperm (three cycles if ≥35).

6 cycles (≤34) or 3 cycles (≥35)

2c: ovulation dysfunction: Member has oligo-ovulation or anovulation treated with medication for at least 6 months (or at least 3 months if ≥35).6 months (or 3 months if ≥35)

2d: specific causes: Member has one of: tubal factor (e.g., bilateral Fallopian tube obstruction); stage 3 or 4 endometriosis; partner with severe male factor infertility.

3. Ovarian reserve assessment (age-based)

3a: age <40: Members with ovaries <40: menstrual history and Day 3 FSH and Estradiol obtained within 2 years.2 years
3b: age ≥40 adequate reserve: Members with ovaries ≥40 must demonstrate adequate ovarian reserve by one of: CCCT within 6 months (Day 3 FSH <15 mIU/ml, Day 3 Estradiol <80 pg/mL, Day 10 FSH <15 mIU/ml); or CCCT within 12 months plus Day 3 FSH <15 and Day 3 Estradiol <80 within 6 months; or AMH >1.0 ng/mL or antral follicle count >6 within 12 months plus Day 3 FSH <15 within 6 months.FSH <15 mIU/ml; Estradiol <80 pg/mL; AMH >1.0 ng/mL; AFC >6
3c: FSH exclusion after 40th birthday: A member with FSH ≥15 mIU/ml at any time after her 40th birthday is ineligible for IVF, donor egg, or ICSI.FSH ≥15 mIU/ml

4. Anatomy assessment: Anatomy Assessment: tubal patency and uterine cavity evaluation as required by service type.HSG/laparoscopy/hysteroscopy/sonohysterogram within 2 years

For AI/IUI: HSG or laparoscopy/hysteroscopy within 2 years. For IVF/FET/donor egg: HSG, laparoscopy/hysteroscopy, sonohysterogram or hysteroscopy within 2 years.

5. Smoking/vaping: If member or partner smoked/vaped within last year, documentation of urine or serum negative cotinine within 1 month of requested service is required.negative cotinine within 1 month

6. Semen analysis: Semen analysis within the past year must be submitted if partnered and applicable; abnormal samples require a second sample within past year; urology consult required for severe male factor.within 1 year; 2 analyses for severe male factor

WHO 6th edition reference for normal thresholds; defined severe male factor thresholds listed separately.

7. Prior treatment documentation: Documentation of all prior treatment and cycle details, including pre- and post-wash semen analyses, must be submitted.

8. Live birth probability: There must be >5% probability that the requested infertility treatment will result in a live birth using the member's own eggs based on clinical history, or the member must meet criteria for donor egg.>5%

AI/IUI Specific Criteria (Medically Necessary)

Covered when ALL General Eligibility Criteria 1-8 are met AND the following:

AI/IUI Specific Criteria

1. Anatomy and ovulation: At least one patent Fallopian tube, normal ovary, and uterine cavity evaluation; spontaneous ovulation or adequate ovarian reserve testing.
2. Indications (any one)
- 2a: unexplained: Unexplained infertility.
- 2b: anovulation: Anovulation (excluding primary ovarian insufficiency/premature ovarian failure).
- 2c: endometriosis: Mild to moderate endometriosis.
- 2d: cervical: Cervical factors.
- 2e: mild-moderate male factor: Mild to moderate male factor infertility meeting specified thresholds: sperm concentration ≥10 million/ml; total sperm count ≥20 million; motility ≥20%; morphology 2% (Strict Kruger) or 20% (WHO 6th); total motile sperm ≥10 million; total motile sperm ≥5 million on washed sample if performed.concentration ≥10M/ml; total ≥20M; motility ≥20%; morphology 2% Kruger or 20% WHO; total motile ≥10M; post-wash ≥5M
- 2f: frozen sperm: Medically necessary use of frozen sperm with normal fertility parameters.

Conversion from IUI to IVF (Medically Necessary)

Covered when IUI cycle met IUI criteria AND ALL of the following:

Conversion from IUI to IVF

1. Estradiol threshold: Current IUI cycle estradiol ≥800 pg/ml.≥800 pg/ml
2. Follicle threshold: Current IUI cycle produced ≥5 follicles >13 mm diameter.≥5 follicles >13 mm

IVF (Medically Necessary)

Covered when General Eligibility Criteria 1-8 are met, with the following conditions:

IVF Coverage Conditions

1. Urology consult for severe male factor: If severe male factor infertility is present, a urology consultation is required.
2. Exclusions for POI/premature ovarian failure: Members with severe premature ovarian failure (age <40, amenorrheic 6 months with menopausal FSH) or primary ovarian insufficiency are not eligible for IVF using their own eggs but can be considered for donor egg.
3. Medication and cryopreservation expectations: Standard medication doses for stimulation are expected; all good-quality embryos should be frozen for future use; cryopreservation covered up to two years for remaining embryos.2 years storage
4. Use of cryopreserved embryos before further cycles: When at least 3 cryopreserved embryos from member ≤37, or ≥4 from member ≥38, these must be used prior to any request for further IVF cycles.3 embryos (≤37) or 4 embryos (≥38)
5. One cycle at a time: No more than one IVF cycle may be approved at a time.1 at a time
6. Single Embryo Transfer (SET) requirements
- 6a: Require SET for the first two IVF cycles when ≥2 good-quality embryos are available at transfer for members <35.
- 6b: Require SET for the first IVF cycle when ≥2 good-quality embryos are available at transfer for members 35-37.
- 6c: SET not required for members >37.

IVF for Members not in Active Infertility Treatment

Covered when member will undergo medical/surgical treatment likely to cause permanent infertility (e.g., chemo, radiation, gender-affirming treatment) and documentation provided:

1. One cycle for preservation: Covers one cycle of IVF for egg retrieval, processing, fertilization and single cryopreservation of eggs/embryos for up to two years.2 years storage
2. Not required to be in active infertility treatment: Member/couple need not be already receiving authorized infertility services.
3. Exclusions for voluntary sterilization: Excludes voluntary sterilization or past voluntary sterilization.
4. Age-related decline exclusion: Not covered for age-related decline; members age 40 and older must demonstrate adequate ovarian reserve per General Eligibility 3b/3c; members up to and including 44 years of age are not eligible.≤44 ineligible; age 40+ must show reserve

Frozen Embryo Transfer (FET)

Covered when General Eligibility Criteria 4b, 5, and 8 are met AND:

FET Conditions

1. Gestational carrier restriction: Request is not related to gestational carrier services (unless plan documents specify otherwise).
2. Embryo source
- 2a: prior approved embryos: Member has frozen embryos from a prior IVF or Donor Egg Cycle approved by Mass General Brigham Health Plan.
- 2b: embryos from other insurer: Embryos were created while the patient was under an insurer other than Mass General Brigham Health Plan AND member met General Eligibility criteria 1-8 either at time of freezing or at time of request.

Donor Egg Services

Covered when General Eligibility Criteria are met AND one of the following indications is present:

Donor Egg Indications and Limits

Indications (any one): premature ovarian failure with onset <40 (Day 3 or random FSH >20 prior to age 40), congenital or surgical absence of ovaries, failed IVF due to poor embryo quantity/quality, or IVF predicted ≤5% probability of live birth.FSH >20 for POF prior to 40; ≤5% live birth probability
Conditions and limits
- Exclusions: age-related decline: Donor egg services excluded for age-related decline; not covered for members ≥44 or members ≥40 with inadequate ovarian reserve.≥44 excluded; ≥40 with inadequate reserve excluded
- Donor age limits: Anonymous or designated donors must be ≤35 years, or 36-39 with normal ovarian reserve per General Eligibility; donors ≥40 not appropriate.donor ≤35 or 36-39 with normal reserve
- Authorization time limit: When criteria met, cycle authorized for up to 6 months; if not performed, new request required.6 months authorization
- Recipient coverage components: Coverage for embryo recipient includes implantation-support medications if member has prescription benefit, egg insemination, embryo transfer, monitoring, and cryopreservation up to two years.2 years storage for remaining embryos
- Donor coverage components: Coverage for egg donor limited to monitoring up to egg retrieval and the retrieval procedure; donor meds covered only if embryo recipient has prescription benefit with the plan.

Cryopreservation of Eggs/Embryos

Covered (with storage up to two years) when authorized and one of the following applies:

1. Embryos not transferred due to high multiple gestation risk: Member receiving authorized IVF or Donor Egg services and embryos should not be transferred during current cycle due to high risk of multiple gestations or high risk to member health (e.g., severe OHSS).
2. Unfertilized mature eggs: Member receiving authorized IVF and there are unfertilized mature eggs due to unexpected lack of sperm for fertilization.
3. Fertility preservation for gonadotoxic treatment: Member will undergo medical/surgical treatment likely to result in permanent infertility (e.g., chemo, radiation, gender affirmation) excluding voluntary sterilization and IVF was authorized for stimulation/retrieval; cryopreservation covered up to two years from retrieval.2 years storage

Cryopreservation of Ovarian Tissue

Covered when authorized and member will undergo gonadotoxic therapy likely to render permanent infertility.

1. Authorization: Authorization required.
2. Storage limit: Storage covered up to two years.2 years

ART when using a Surrogate/Gestational Carrier

One cycle of oocyte stimulation/retrieval/fertilization may be authorized when General Eligibility Criteria 1,3,5,6,7,8 are met AND both conditions below:

ART with Surrogate/Gestational Carrier

1. Medical contraindication to pregnancy: Member has clear medical contraindication to pregnancy due to uncorrectable structural uterine abnormality or life-threatening condition (documentation required).
2. Own oocytes and self-payment for carrier: Member is using their own oocytes and self-paying for a gestational carrier.
3. Donor egg and gestational carrier exclusion: Use of donor egg(s) with a gestational carrier or transfer of embryo(s) to a gestational carrier is not covered unless specified in plan documents; implantation-related services and pregnancy-related services for gestational carrier are not covered.

Donor Sperm / Therapeutic Donor Insemination (TDI)

Covered for members meeting General Eligibility Criteria with partner diagnosed with moderate to severe male factor infertility:

Donor Sperm / TDI

1. Vial limits: Coverage limited to no more than one vial per IUI or IVF cycle.1 vial per cycle
2. Donor quality: Donor sperm must be of normal quality.meets normal fertility thresholds

MESA

Covered one per lifetime when ALL of the following are met:

1. Azoospermia with normal testicular function: Member has azoospermia with normal testicular function evidenced by normal testes exam, FSH, and testosterone.
2. Causes (any): Azoospermia due to CBVAD, vas deferens stricture, atrophy/fibrosis of spermatic cord/vas deferens, or extra-testicular obstructive causes (excluding prior sterilization or sterilization reversal).

TESE

Covered one per lifetime for non-obstructive azoospermia when ALL of the following are met:

1. Non-obstructive azoospermia: Azoospermia is non-obstructive and not due to suppression by anabolic steroids.
2. Not amenable to other treatments: Azoospermia not amenable to other treatments such as hormonal therapy for hypogonadotropic hypogonadism.
3. Genetic testing prior to TESE: A Y chromosomal microdeletion assay and karyotype must be performed prior to TESE to rule out genetic traits predicting failure of sperm retrieval.

Cryopreservation of Sperm

Covered with storage up to two years when one of the following applies:

1. MESA/TESE retrieved sperm: Member diagnosed with a medical condition (not from prior voluntary sterilization) requiring sperm obtained directly via authorized MESA or TESE for ongoing infertility treatment.
2. Neurologic/psychologic inability to produce sample: Member has neurological/psychological condition (not due to prior voluntary sterilization) interfering with ability to produce a sample on day of authorized infertility procedure; confirmed diagnosis required.
3. Fertility preservation for gonadotoxic therapy: Member will undergo medical/surgical treatment likely to result in permanent infertility (e.g., chemo, radiation, gender affirmation), excluding voluntary sterilization; >5% probability of future live birth using cryopreserved sperm; storage up to two years from retrieval.>5% probability; 2 years storage

Sterilization Reversal - Eligibility

Medically necessary infertility services authorized after successful reversal only when ALL of following are documented:

1. Vasectomy reversal: For a vasectomy reversal: a semen analysis with normal fertility thresholds documenting success, followed by an age-applicable period of attempting natural conception, and then two semen analyses within 3 months of the request demonstrating continued success.two semen analyses within 3 months
2. Tubal ligation reversal: For a tubal ligation reversal: post-surgical HSG or chromotubation or HyCoSy demonstrating unilateral/bilateral free spill, followed by an age-applicable attempting period, then HSG or chromopertubation within 3 months of request showing no post-op scarring/blockage and no ectopic pregnancies since reversal.HSG/contrast test within 3 months
3. General eligibility: Member/couple otherwise meets all General Eligibility Coverage Criteria.
4. Independence of need: Need for infertility services must be clearly independent of prior sterilization procedure.

Regulatory Coverage Constraints (Massachusetts 211 CMR 37.08 & 37.09)

State regulatory constraints and permissible limitations:

Regulatory Constraints (MA 211 CMR 37.08 & 37.09)

1. Prohibited differing limitations: Insurer shall not impose deductibles, copayments, coinsurance, benefit maximums, waiting periods, or other limitations on required infertility benefits that are different from those for non-infertility services.
2. Pre-existing exclusion prohibition: Insurer shall not impose pre-existing condition exclusions or waiting periods on required infertility benefits; prior diagnosis or treatment for infertility cannot be used to exclude or limit coverage.
3. Arbitrary limitation prohibition: Insurer shall not impose limitations on coverage based solely on arbitrary factors such as number of attempts or dollar amounts.
4. Clinical guidelines requirement: Limitations on coverage shall be based on clinical guidelines and the insured's medical history; clinical guidelines must be written and available on request. Standards from ASRM, ACOG, or SART may serve as basis.

Submit full prior treatment and cycle details

Documentation Required

Ovarian reserve and uterine/tubal evaluation timing

Document ovarian reserve and uterine/tubal evaluation within specified timeframes: HSG, laparoscopy, hysteroscopy, or sonohysterogram for uterine/tubal assessment performed within the past 2 years for AI/IUI (tubal patency/uterine contours) and for IVF/FET/donor egg requests. Ovarian reserve testing timing: members <40 — menstrual history plus Day 3 FSH and estradiol obtained within 2 years; members ≥40 — one of: CCCT within past 6 months (Day 3 FSH <15, Day 3 estradiol <80 pg/mL, Day 10 FSH <15), or CCCT within past 12 months plus Day 3 FSH/estradiol within 6 months, or AMH >1.0 ng/mL or AFC >6 within past 12 months plus Day 3 FSH within 6 months.

Uterine/tubal evaluation (HSG, laparoscopy/hysteroscopy, or sonohysterogram) within 2 years
Members <40: Day 3 FSH and estradiol within 2 years
Members ≥40: CCCT timing and thresholds (see parameters) or AMH/AFC timing with Day 3 FSH within 6 months
FSH ≥15 after 40th birthday renders member ineligible (see age-based criteria)

Documentation Required

Smoking/vaping cessation documentation

If the member or partner smoked or vaped within the last year, providers must submit urine or serum negative cotinine levels within one month of the requested service. For abnormal semen samples, smoking cessation for at least 3 months is a recommended reversible-cause intervention and may be required per policy/exclusions.

Negative urine or serum cotinine within 1 month of service if member or partner smoked/vaped in last year
Smoking cessation for at least 3 months recommended/required when applicable (e.g., reversible cause of abnormal semen)

Documentation Required

Urology consult for severe male factor

Document a urology consultation for cases of severe male factor infertility. This urology consult is required prior to authorization of IVF or ICSI when severe male factor is present.

Urology consult required for severe male factor infertility
Must be documented before IVF/ICSI authorization when severe male factor is present

Billing Rule

Limits on cycles and procedures

Limits and lifetime/service-specific restrictions: only one IVF cycle may be approved at a time; MESA and TESE are covered one time per lifetime; donor egg cycles are authorized for up to 6 months; donor sperm coverage is limited to one vial per IUI or IVF cycle.

One IVF cycle approved at a time
MESA: one per lifetime
TESE: one per lifetime
Donor egg cycle authorization valid for up to 6 months
Donor sperm limited to one vial per IUI or IVF cycle

Documentation Required

Genetic testing prior to TESE

For TESE requests, a Y chromosome microdeletion assay and karyotype must be performed and documented prior to the procedure to rule out genetic traits predicting failure of sperm retrieval.

Y chromosome microdeletion assay required prior to TESE
Karyotype required prior to TESE

Denial Risk

Age-based ineligibility

Members with uteri/ovaries aged 44 years or older are ineligible for assisted reproductive services. Additionally, any member with an FSH greater than or equal to 15 mIU/mL at any time after her 40th birthday is ineligible for IVF, donor egg, or ICSI.

Members ≥44 years are ineligible for assisted reproductive services
FSH ≥15 after 40th birthday excludes eligibility for IVF, donor egg, and ICSI

Documentation Required

Clinical guidelines availability

Clinical guidelines and the written clinical guidelines used to set permissible limitations must be maintained in written form and be available to any insured upon request. The policy references ASRM/ACOG/SART as acceptable bases for these guidelines.

Maintain written clinical guidelines
Make guidelines available on request
ASRM, ACOG, or SART standards may serve as basis

Documentation Required

Urology consult for severe male factor infertility (policy history notes)

Policy history and revisions note that a urology consult is required for cases of severe male factor infertility and that this requirement is reflected in the policy language and revision history.

Revision history clarifies requirement for urology consult in severe male factor cases
Urology consult requirement appears in policy text for ICSI/IVF sections

January 2026revised

Ad hoc review updated prior authorization table and table of contents and added variation for One Care and SCO members (January 2026).

April 2026revisedLatest

Ad hoc review: policy reformatted; clarified criteria hierarchy for One Care and SCO; updated summary of evidence and references (April 2026).