Mass General Brigham Health Plan IVF Coverage Update

Coverage and Medical Necessity Criteria

General Eligibility Coverage Criteria

Covered when ALL of the following General Eligibility Criteria are met

General Eligibility: 1. The member must be an individual in whom fertility would be expected; if infertility is identified, refer to the Infertility Services policy. 2. There must be a greater than 5% probability that the requested treatment will result in a live birth based on clinical history (pregnancy history, menopausal status, diagnosis, BMI, semen analysis, and response to previous cycles and fertility treatments). 3. Documentation of all prior treatment and cycle details, including pre- and post-wash semen analyses when applicable, must be submitted. 4. The member must be the recipient of the requested service.

Artificial Insemination/Intrauterine Insemination (AI/IUI)

AI/IUI covered when ALL of the following are met

IUI criteria: 1. Member with ovaries/uteri meets General Eligibility Coverage Criteria and donor sperm is a covered service per the member's Schedule of Benefits/Summary of Benefits and Coverage/Benefit Handbook. 2. Tubal patency and adequate uterine contours demonstrated by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy performed within the past 2 years. 3. Adequate ovarian reserve demonstrated by one of: (a) members <40 years — menstrual history and Day 3 FSH and Estradiol within 2 years; (b) members ≥40 years — menstrual history and either (i) CCCT within 6 months with Day 3 FSH <15 mIU/ml, Day 3 Estradiol <80 pg/mL, and Day 10 FSH <15 mIU/ml; or (ii) CCCT within 12 months plus Day 3 FSH and Estradiol within 6 months meeting same thresholds; or (iii) AMH >1.0 mg/mL or antral follicle count >6 within 12 months and Day 3 FSH <15 mIU/mL within 6 months. 4. If the member or partner smoked/vaped within the last year, urine or serum negative cotinine documented within 1 month of the requested service.

Detailed ovarian reserve timing rules applied as specified in the policy.

Conversion from IUI to IVF

Conversion from IUI to IVF covered when BOTH are met

IUI to IVF conversion: 1. The current IUI cycle met IUI criteria. 2. Current IUI cycle produced an estradiol level ≥ 800 pg/mL. 3. Current IUI cycle produced at least 5 follicles >13 mm in diameter.

Conversion is covered when the IUI cycle met IUI criteria and both numeric thresholds are met.

In Vitro Fertilization (IVF)

IVF covered when ALL of the following are met

IVF authorization requirements: 1. Member with ovaries/uteri meets General Eligibility Coverage Criteria and has Health Plan authorization for preimplantation genetic testing (or is a GIC member eligible for IVF/reciprocal IVF). 2. Adequate uterine contours demonstrated by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy within the past 2 years (waived for the egg donor in reciprocal IVF). 3. Adequate ovarian reserve demonstrated by one of: (a) members <40 years — menstrual history and Day 3 FSH and Estradiol within 2 years; (b) members ≥40 years — demonstrate via CCCT or alternative timing per policy (see detailed CCCT/AMH/AF count and FSH rules). 4. If member or partner smoked/vaped within last year, urine or serum negative cotinine within 1 month of requested service. 5. Semen analysis within past year if partnered; follow-up and urology consult required for severe male factor per WHO thresholds. 6. Standard stimulation medication doses expected and all good quality embryos frozen for future use; cryopreservation covered up to two years. 7. No more than one IVF cycle approved at a time. 8. Single Embryo Transfer (SET) required for first cycles by age: first two cycles if <35; first cycle if 35–37; not required if >37.

Members with FSH ≥15 mIU/ml at any time after their 40th birthday are ineligible for IVF, donor egg, or ICSI.

Frozen Embryo Transfer (FET)

FET covered when ALL of the following are met

Frozen Embryo Transfer: 1. Request is not related to gestational carrier services unless specified in the member's Schedule of Benefits/Summary of Benefits and Coverage/Benefit Handbook. 2. Tubal patency and adequate uterine contours demonstrated by hysterosalpingogram, sonohysterogram, or laparoscopy/hysteroscopy within the past 2 years. 3. Frozen embryos available from a prior IVF cycle and one of: (a) the IVF or donor egg cycle was approved by the Health Plan; (b) the recipient met General Eligibility criteria at time of freezing or at time of request; (c) embryos underwent preimplantation genetic testing and recipient met PGT authorization criteria; or (d) recipient is enrolled in a GIC plan.

Donor Eggs and Donor Sperm

Donor gamete coverage

Donor eggs (GIC) and donor sperm: 1. Donor eggs: covered for GIC members with testes who do not have a partner who can produce fertilizable eggs; a semen analysis within one year is required. 2. Donor sperm: covered for members with ovaries/uteri when IUI or IVF authorization criteria are met and the member's Schedule of Benefits confirms coverage; one vial of donor sperm is authorized per IUI or IVF cycle.

Severe male factor may allow eligibility for donor sperm; follow plan benefits.

Cryopreservation

Cryopreservation covered when ANY of the following are met

Cryopreservation of eggs/embryos: 1. Member is receiving Plan-authorized IVF or Donor Egg services and embryos should not be transferred during the current cycle due to (a) high risk of multiple gestations from transferring an excessive number of embryos, or (b) high probability of adverse impact on the member's health (e.g., severe ovarian hyperstimulation syndrome). 2. Member is receiving Plan-authorized IVF and there are unfertilized mature eggs due to unexpected lack of sperm for fertilization.

Storage for cryopreserved eggs/embryos is covered up to two years.

Assisted Reproductive Technology with Surrogate/Gestational Carrier

ART with gestational carrier covered when ALL of the following are met

ART with gestational carrier: 1. Member meets General Eligibility Criteria as specified in the Infertility Services policy (General Eligibility items 1, 3, 5, 6, 7, and 8 referenced) and has a clear medical contraindication to pregnancy due to an uncorrectable structural uterine abnormality or a life‑threatening condition (documentation required). 2. Member is using own oocytes and is self‑paying for the gestational carrier. 3. Use of donor eggs with a gestational carrier or transfer of embryos to a gestational carrier is not covered for members with ovaries unless specified in the member's Schedule of Benefits; implantation- and pregnancy-related services for the gestational carrier are not covered.

One cycle of oocyte stimulation, retrieval, and fertilization may be authorized under these conditions.

Cryopreservation of Eggs/Embryos

Covered when ONE of the following is met:

Cryopreservation qualifying criteria: 1) Member receiving Plan-authorized IVF or Donor Egg services and embryos should not be transferred during the current cycle due to either (a) high risk of multiple gestations from transferring excessive embryos, OR (b) high probability of adverse impact on the member's health (e.g., severe OHSS); OR 2) Member receiving Plan-authorized IVF and there are unfertilized mature eggs due to unexpected lack of sperm for fertilization.

Covers cryopreservation and up to two years' storage.

ART When Using a Surrogate/Gestational Carrier

Covered when ALL of the following are met:

Gestational carrier criteria: 1) Member meets General Eligibility Criteria items referenced in the Infertility Services guideline (items 1,3,5,6,7,8) AND 2) Member has a clear medical contraindication to pregnancy (uncorrectable structural uterine abnormality or life‑threatening condition) with documentation; AND the member is using own oocytes and self‑paying for the gestational carrier.

Use of donor eggs with a gestational carrier or transfer to a gestational carrier is not covered for members with ovaries unless specified in benefits; gestational carrier implantation and pregnancy services are excluded.

Intracytoplasmic Sperm Injection (ICSI)

ICSI is covered when the member meets coverage criteria for IVF AND at least one documented condition is present

ICSI indications: 1. Total failed or near‑total (<50%) fertilization of mature eggs on a prior IVF cycle with standard insemination. 2. Need for coverage of preimplantation genetic testing (PGT) per the PGT medical necessity guidelines. 3. Need to fertilize cryopreserved eggs. 4. Day‑of‑retrieval post‑processing semen analysis meets ICSI criteria — retrospective authorizations allowed. Note: ICSI is not authorized for IVF cycles using donor sperm.

Member must meet IVF coverage criteria in addition to one of the listed indications.

Cryopreservation of Sperm

Covered when ALL of the following are met:

Sperm cryopreservation criteria: 1. Member has a neurological or psychological condition (not due to prior voluntary sterilization) that interferes with ability to produce a sperm sample on the day of an authorized fertility procedure; AND 2. Member has a confirmed diagnosis requiring sperm be obtained in advance and cryopreserved for ongoing fertility treatment.

Cryopreservation and up to two years' storage are covered.

Donor Egg/Sperm to Reduce Genetic Transmission

Covered when ALL of the following are met:

Donor gamete for genetic risk: 1. Mass General Brigham Health Plan has authorized preimplantation genetic testing for structural rearrangement (PGT‑SR) or monogenic disease (PGT‑M). 2. Mass General Brigham Health Plan has authorized IVF.

Egg donor recommended age 21–35 with Day 3 FSH <10 mIU/ml and Estradiol <80 pg/mL OR AMH >2 ng/mL as specified.

Mass General Brigham Health Plan does not provide coverage for assisted reproductive services for MassHealth members and members of certain Custom Plans; to determine coverage for a Custom Plan, refer to the member's Schedule of Benefits, Summary of Benefits and Coverage, Benefit Handbook, and/or amendments. This policy also notes that assisted reproductive services are not a covered service for Mass General Brigham ACO members who are not also enrolled in Medicare.

Exclusions include, but are not limited to: members who do not have a fertility benefit; members who are menopausal, perimenopausal, or not naturally expected to be fertile; services requested for convenience or non‑medical preference; fertility treatment with ≤5% chance of live birth; reversal of voluntary sterilization; donor sperm in the absence of a male partner except when authorized by the member's benefits; monitoring of non‑authorized IUI cycles; storage of cryopreserved material beyond 2 years; cryopreservation of testicular tissue; elective embryo discard for gender selection; embryonic research; IUI/IVF/ICSI using donor sperm that is not of normal quality; non‑medical donor procurement fees; fertility medications for anonymous donors when services are not approved; services when the member or partner is using illicit substances or misusing substances that negatively affect fertility or fetal development; services when the member or partner smokes and has not abstained for at least 3 months; and assisted reproductive services for a member with ovaries/uterus who is age 44 or older.

The policy was updated in April 2026 to reformat the document and to explicitly remove the tubal patency requirement for IVF; this change means tubal patency is no longer a preauthorization requirement for IVF in the general coverage criteria.

Members with a documented serum FSH ≥ 15 mIU/mL at any time after their 40th birthday are ineligible for IVF, donor egg, or ICSI and therefore these services are treated as not covered for those members.

Investigational or experimental procedures and treatments that are not supported by the scientific body of evidence are not covered. Services requested for convenience or non‑medical reasons are likewise considered not medically necessary and are excluded from coverage.

Informational and Billing Codes

Informational Codes (S-codes)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.

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Informational ART S-codesHCPCS

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.

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inv-21: Estradiol for IUI conversion — threshold value required

Estradiol threshold for IUI-to-IVF conversion>= 800 pg/ml

ContextConversion is covered when the IUI cycle met IUI criteria and estradiol >= 800 pg/ml

Source noteApplies to current IUI cycle leading to inadvertent ovarian hyperstimulation

inv-22: Number of follicles for IUI conversion — numeric threshold

Follicle count threshold for IUI-to-IVF conversion>= 5 follicles >13 mm

ContextApplies to production of follicles in the current IUI cycle when converting to IVF due to inadvertent ovarian hyperstimulation

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage, One Care/SCO, and Commercial plans. Verify the member's Schedule of Benefits, Summary of Benefits and Coverage, Benefit Handbook, and/or plan amendments to confirm coverage and any plan-specific limits before requesting services. Mass General Brigham Health Plan uses CMS guidance (NCDs, LCDs, LCAs) for Medicare Advantage, One Care, and SCO members; when CMS guidance is absent or criteria are not met for those members, MassHealth criteria apply for One Care/SCO. Services must be authorized by the Health Plan prior to delivery.

January 2026: Prior authorization table updated and One Care/SCO variations added; refer to plan-specific prior authorization requirements.
Commercial members: Members age 44 or older with uteri/ovaries are not eligible for assisted reproductive services per plan criteria—verify age and fertility status.
Services must meet medical necessity and plan coverage; when CMS guidance exists it governs Medicare populations.

Documentation Required

Eligibility and Benefit Verification

Definitions and Key Terms

inv-38: Members without a diagnosis of infertility — members to whom this document's criteria apply; those with infertility diagnoses should refer to the Infertility Services policy.

Applies to members without infertility diagnosisThis policy defines coverage criteria for assisted reproductive services for members without a diagnosis of infertility

Infertility referralsMembers with a diagnosis of infertility or undergoing treatments likely to cause infertility should refer to the Infertility Services policy

Benefit exclusions noteMass General Brigham Health Plan does not provide coverage for assisted reproductive services for MassHealth members and certain Custom Plans—refer to Schedule of Benefits

inv-39: Infertility — Definition including timeframe (one year if ≤35; six months if >35) and notes for those without sperm exposure.

DefinitionInfertility is inability to conceive after one year if age <=35 or after six months if age >35

Background and Scope

This policy defines coverage for assisted reproductive services for members without a diagnosis of infertility and directs members with a diagnosis of infertility or who will undergo treatments likely to cause infertility to the separate Medical Necessity Guidelines for Infertility Services. Coverage determinations reference clinical criteria including ovarian reserve testing, uterine anatomy, semen analysis, and an estimated probability of live birth; note the policy limits services by plan (e.g., MassHealth, Custom Plans) and includes plan‑specific prior authorization requirements.

OpenPayer

Assisted Reproductive Services / Fertility Services — Coverage Criteria

Coverage and Medical Necessity Criteria

Informational and Billing Codes

Provider Requirements, Prior Authorization, and Documentation

Definitions and Key Terms

Background and Scope