CurrentMass General Brigham Health PlanPolicy 089

Fertility Services/Assisted Reproductive Services

Medical necessity coverage criteria for assisted reproductive services (ART, IUI, IVF, ICSI, donor gametes, cryopreservation, FET, surrogate/gestational carrier rules) for Mass General Brigham Health Plan members without a diagnosis of infertility; includes plan-specific variations (Medicare Advantage, One Care/SCO, Commercial, GIC) and exclusions. Part 1 of 2.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFertility Services/Assisted Reproductive Services

Policy CodePolicy 089

Change TypeAd hoc updates (formatting, clarifications)

Effective DateJul 1, 2025

Next Review Date

Key ActionPrior authorization is required for Medicare Advantage, One Care/SCO, and Commercial plans; services must be authorized by the Health Plan before IVF medications are covered and services delivered.

SourceLink

POLICY UPDATE CHANGES

April 2026 ad hoc update: Reformatted policy, removed tubal patency requirement for IVF, clarified criteria hierarchy in One Care and SCO section.

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

September 2025 ad hoc update: Clarified need for urology consult for severe male factor infertility and added definition of Assisted Reproductive Services.

30+Covered Service Types Listed

2 yearsCryopreservation storage limit

IVF cycles approved at a time

>=5%Minimum probability of live birth to consider treatment

MultipleReferences listed

Coverage Summary

This policy defines medical necessity criteria for assisted reproductive services (including ART, IUI, IVF, ICSI, donor gametes, cryopreservation, and FET) for members without a diagnosis of infertility. Plan variations: prior authorization is required for Medicare Advantage, One Care/SCO, and Commercial plans; Mass General Brigham ACO members are not covered unless also enrolled in Medicare; GIC plans have additional covered services (e.g., reciprocal IVF, donor egg for certain members). IVF medications are covered only if the IVF or medicated IUI services have been approved by the Health Plan.

Key thresholds: the member must have a > 5% probability of live birth to be considered for treatment; conversion from IUI to IVF requires current IUI estradiol ≥ 800 pg/mL and ≥ 5 follicles > 13 mm; a member with FSH ≥ 15 mIU/mL at any time after her 40th birthday is ineligible for IVF/donor egg/ICSI; ovarian reserve markers include AMH > 1.0 mg/mL (some criteria) and donor egg AMH > 2 ng/mL; cryopreservation storage is covered up to 2 years; no more than one IVF cycle may be approved at a time.

Key thresholds and limits

Probability of success threshold> 5% chance of live birth

IUI→IVF conversion - estradiol threshold>= 800 pg/mL on current IUI cycle

IUI→IVF conversion - follicle count>= 5 follicles > 13 mm in diameter on current IUI cycle

FSH cutoff after age 40FSH ≥ 15 mIU/mL at any time after 40 years -> ineligible for IVF, donor egg, or ICSI

AMH / antral follicle thresholdsAMH > 1.0 ng/mL or antral follicle count > 6 (used for ovarian reserve in members ≥40); donor egg AMH > 2 ng/mL (donor criteria)

Cryopreservation storage limitCryopreservation and storage covered up to 2 years

Medical‑Necessity Criteria

General Eligibility Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

The member must be an individual in whom fertility would be expected (not menopausal or perimenopausal).
There must be a greater than 5% probability that the treatment being requested will result in a live birth based on clinical history including pregnancy history, menopausal status, diagnosis, BMI, semen analysis and response to previous cycles and fertility treatments.> 5% chance of live birth
Documentation of all prior treatment and cycle details, including pre- and post-wash semen analyses where applicable, must be submitted.

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for Medicare Advantage, One Care/SCO, and Commercial plans. IVF medications are covered only if the IVF or medicated IUI services have been authorized by the Health Plan prior to medication coverage and service delivery.

Documentation Required

Submit prior treatment and cycle details

Submit documentation of all prior treatment and cycle details with any request for assisted reproductive services. This must include pre- and post-wash semen analyses where applicable.

Coding

Informational HCPCS S-codes (included for informational purposes only)HCPCS

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.
S4022	Assisted oocyte fertilization, case rate.

1–10 of 20

1/2

Background, Evidence & Definitions

This policy references Massachusetts regulation 211 CMR 37.00 (Infertility Benefits) when describing required and optional infertility procedures and permitted limitations. The policy aligns covered services with the regulation’s list of non-experimental infertility procedures (e.g., AI/IUI, IVF-ET, ICSI, cryopreservation) and with Mass General Brigham Health Plan clinical criteria.

Plan variations: Medicare Advantage, One Care and SCO members follow CMS guidance and require prior authorization; when CMS guidance is lacking, the Plan’s medical policies are used. One Care/SCO apply Medicare criteria first and, if not met, MassHealth criteria. Commercial and Qualified Health Plans may limit coverage based on the member’s Schedule of Benefits and require prior authorization; GIC plans have broader covered services (including reciprocal IVF and donor egg options for eligible members).

IVF medications are only covered when the IVF or medicated IUI services themselves have been authorized by Mass General Brigham Health Plan; the policy explicitly states that the Plan provides coverage for fertility medications only if the IVF or medicated IUI services are approved.

Source Type	Reference
Regulation referenced	Massachusetts Regulations 211 CMR 37.00
Clinical guidance sources	ASRM, ACOG, SART practice committees and multiple cited studies/reports
Type of sources	Peer‑reviewed journals, professional society committee opinions, CDC/WHO reports, health technology assessment

Artificial Insemination (AI): Placement of semen into the vagina with a syringe rather than through intercourse.

IUI (Intrauterine Insemination): Placement of washed sperm directly into the uterine cavity via catheter.

ICSI (Intracytoplasmic Sperm Injection): Injection of sperm into an egg for fertilization.

SET (Single Embryo Transfer): Transfer of a single embryo at either the cleavage stage (day 2 or 3) or blastocyst stage (day 5 or 6) selected from a larger number of available embryos.

Revision History

2025-07-01effective_date

Policy effective date established.

September 2025ad_hoc_update

Clarified need for urology consult when addressing male factor infertility; added definition of Assisted Reproductive Services; updated code disclaimer, hyperlinks, references, and simplified first paragraph under Coverage Guidelines.

January 2026ad_hoc_update

Administrative and formatting updates: updated prior authorization table and table of contents, added variation for One Care and SCO members, and fixed formatting.

Policy Summary

PayerMass General Brigham Health Plan

PolicyFertility Services/Assisted Reproductive Services

Policy CodePolicy 089

Change TypeAd hoc updates (formatting, clarifications)

Effective DateJul 1, 2025

Next Review Date

SourceLink

On This Page

The member must be the recipient of the requested service.

Artificial Insemination (AI)/Intrauterine Insemination (IUI) Authorization Criteria

Covered when ALL of the following are met:

ALL of the following

Member meets General Eligibility Criteria.
Member's Schedule of Benefits confirms donor sperm is a covered service.
Tubal patency and adequate uterine contours demonstrated by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy performed within the past 2 years.within past 2 years
ONE of
- For members with ovaries < 40 years: menstrual history and Day 3 FSH and Estradiol within 2 years.within 2 years
- ALL of the following
  - CCCT within past 6 months showing Day 3 FSH < 15 mIU/ml, Day 3 Estradiol < 80 pg/mL, and Day 10 FSH < 15 mIU/ml.Day3 FSH <15; Day3 E <80; Day10 FSH <15; within 6 months
  - CCCT within past 12 months meeting above parameters AND Day 3 FSH < 15 mIU/ml and Day 3 Estradiol < 80 pg/mL within past 6 months.CCCT within 12 months + Day3 labs within 6 months
  - AMH > 1.0 mg/mL or antral follicle count > 6 within past 12 months AND Day 3 FSH < 15 mIU/mL within past 6 months.AMH > 1.0 mg/mL or AFC >6; Day3 FSH <15 within 6 months
If member or partner smoked/vaped within last year, documentation of urine or serum negative cotinine within one month of requested service.negative cotinine within 1 month

IVF (with preimplantation genetic testing authorization or GIC members)

Covered when ALL of the following are met:

ALL of the following

Member has ovaries/uteri and meets General Eligibility Criteria.
Mass General Brigham Health Plan authorization for preimplantation genetic testing (PGT) OR member is GIC plan and meets GIC-specific allowance.
Adequate uterine contours demonstrated by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy within past 2 years (waived for egg donor in reciprocal IVF).within past 2 years; waived for egg donor in reciprocal IVF
ANY of the following
- Members with ovaries < 40: menstrual history and Day 3 FSH and Estradiol within 2 years.within 2 years
- Members with ovaries ≥ 40: menstrual history AND one of: CCCT within past 6 months (Day 3 FSH <15, Day 3 E <80, Day10 FSH <15) OR CCCT within 12 months plus Day3 labs within 6 months OR AMH >1.0 mg/mL or AFC >6 within 12 months AND Day3 FSH <15 within 6 months.see criteria
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 after age 40 -> ineligible
If member or partner smoked/vaped within last year, documentation of urine or serum negative cotinine within one month of requested service.negative cotinine within 1 month
Semen analysis within past year must be submitted if partnered and applicable; abnormal results require second sample within past year, evaluation and treatment of reversible causes including smoking cessation for at least 3 months; urology consult required for severe male factor infertility.within past year
Standard medication doses for stimulation expected and all good quality embryos frozen for future use. Cryopreservation covered up to two years for remaining embryos.cryopreservation up to 2 years
No more than one IVF cycle may be approved at a time.1 IVF cycle at a time
Single Embryo Transfer (SET) requirements
- For members < 35 years: SET required for the first two IVF cycles.first two cycles
- For members 35-37 years: SET required for the first IVF cycle.first cycle
- For members > 37 years: SET not required.

Frozen Embryo Transfer (FET)

Covered when ALL of the following are met:

ALL of the following

General Eligibility Criteria are met.
Request is not related to gestational carrier services (unless specified in member documents).
Tubal patency and adequate uterine contours demonstrated within past 2 years by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy.within past 2 years
ANY of the following
- The IVF or donor egg cycle was approved by Mass General Brigham Health Plan.
- Recipient met General Eligibility criteria in the Infertility Services/Assisted Reproductive Services policy (at time of freezing or FET request).
- Embryos were subjected to preimplantation genetic testing and recipient met PGT authorization criteria.
- Recipient is enrolled in a GIC plan.

Documentation Required

Tubal patency and uterine contour tests

Demonstration of tubal patency and adequate uterine contours is required by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy performed within the past 2 years for most services (IUI, FET, IVF). This tubal patency/uterine contour requirement is waived for the egg donor in a reciprocal IVF procedure.

Documentation Required

Semen analysis requirements

When partnered, submit a semen analysis performed within the past year. If the initial sample is abnormal, obtain a second sample within the past year; if still abnormal, evaluate and treat reversible causes (including smoking cessation when applicable). A urology consult is required for severe male factor infertility.

Billing Rule

Donor sperm authorization

One vial of donor sperm is authorized per IUI or IVF cycle.

Denial Risk

Age-related denial risk

Members with uteri/ovaries aged 44 or older are not eligible for assisted reproductive services. Services are excluded for members with a ≤5% chance of live birth. For members after age 40, an FSH result ≥ 15 mIU/ml at any time after the 40th birthday renders the member ineligible for IVF, donor egg, or ICSI.

Billing Rule

Cryopreservation storage limit

Cryopreservation (eggs, embryos, sperm) is covered with storage up to two years. Storage or cryopreservation beyond two years is excluded.

Documentation Required

Smoking/documentation requirement

If the member or partner smoked or vaped within the last year, provide a urine or serum negative cotinine test within one month of the requested service. Members and partners must have abstained from smoking for at least 3 months; services are excluded if this abstinence requirement is not met.

CCCT (Clomiphene Citrate Challenge Test): Test to assess ovarian reserve measuring FSH and estradiol response to clomiphene (FSH on cycle Days 3 and 10; estradiol on Day 3).

April 2026ad_hoc_updateLatest

Reformatted policy and removed tubal patency requirement for IVF; clarified criteria hierarchy in One Care and SCO section.