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    v1.0.30
    OpenPayerPolicy UpdatesReproductive Health & FertilityMedStar Family Choice Fertility Coverage | OpenPay…
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    CurrentMedStar Family ChoicePolicy 1433

    Fertility Preservation Services

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    This policy governs when MedStar Family Choice may approve fertility preservation procedures for members whose medically necessary treatment may directly or indirectly cause iatrogenic infertility. All fertility preservation services require prior authorization and medical director review.

    Policy Summary
    PayerMedStar Family Choice
    PolicyFertility Preservation Services
    Policy CodePolicy 1433
    Change TypeNo material change
    Effective DateN/A
    Last ReviewJul 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization requests for all fertility preservation procedures for medical director review.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    RequiredPrior authorization and medical director review
    3 monthsAuthorization period when criteria are met
    3 max

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Covered ovarian stimulation and oocyte preservation cycles
    One-timeBenefit for ovarian tissue and sperm cryopreservation
    Not coveredStorage and banking of sperm or oocytes

    Fertility Preservation Coverage Criteria

    General fertility preservation approval

    Fertility preservation services may be approved when all applicable criteria are met.

    General approval criteria

    • Eligible age: The member is of reproductive age, from puberty to before menopause, or qualifies for the ovarian tissue preservation exception.Puberty to before menopause

      Ovarian tissue preservation has a separate prepubertal exception.

    • Qualifying medical indication: The services are needed because medically necessary treatment may directly or indirectly cause iatrogenic infertility, including impairment caused by surgery, radiation, chemotherapy, gender-affirming treatment, or other treatment affecting reproductive organs or processes.
    • Qualified provider: The services are performed by, and the request comes from, a board-certified reproductive endocrinologist.Board-certified reproductive endocrinologist
    • Minor consent when applicable: If the member is a minor, parental consent is obtained in accordance with current Maryland Minor Consent Laws.

      Applies only when the member is a minor.

    • Complete treatment plan: A complete treatment plan for the proposed fertility preservation services is submitted.

    Gonadal suppression with GnRH analogs

    GnRH suppression may be approved only when all criteria are met.

    GnRH analog criteria

    • Breast cancer indication: The member has breast cancer and GnRH agonist treatment is intended to reduce the risk of premature ovarian insufficiency.
    • Alternative preservation assessment: GnRH analogs are not used in place of other fertility preservation alternatives.

    Ovarian tissue cryopreservation

    Ovarian tissue cryopreservation may be approved when all criteria are met.

    Ovarian tissue criteria

    • Accepted indication

      • Insufficient time: There is insufficient time for oocyte retrieval.
      • Prepubertal member: The member is prepubertal.
    • No malignancy: The ovarian tissue does not have any malignancy.No malignancy

    Non-covered fertility services include donor sperm, donor oocytes, intrauterine insemination, and in vitro fertilization. The policy also excludes storage or thawing of testicular tissue, including associated charges; prepubertal testicular tissue cryopreservation; thawing of cryopreserved sperm or oocytes; and medications not approved by the FDA.

    Sperm and oocyte storage or banking are not covered benefits. Related storage arrangements and charges are also excluded. Practitioners must discuss storage or banking provisions with the member and document the arrangements in the medical record submitted to MedStar Family Choice.

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Prior Authorization and Medical Director Review

    Obtain prior authorization for all fertility preservation procedures before services are provided. Every request requires medical director review.

    Documentation Required

    Treatment Plan and Iatrogenic Infertility Documentation

    Submit the complete treatment plan for the proposed fertility preservation services and documentation showing that medically necessary treatment may directly or indirectly cause iatrogenic infertility.

    • Documentation may include fertility impairment related to surgery, radiation, chemotherapy, gender-affirming treatment, or another medical treatment or intervention affecting reproductive organs or processes.
    Documentation Required

    Policy Background

    Fertility preservation services are intended to preserve fertility before medically necessary treatment that may directly or indirectly cause iatrogenic infertility. Such infertility may result from surgery, chemotherapy, radiation treatment, gender-affirming treatment, or other treatment affecting the reproductive organs or processes. Covered preservation services are distinct from infertility services and must be consistent with applicable professional guidelines.

    Key Policy Definitions

    Medically Necessary Treatment That May Cause Iatrogenic Infertility
    DefinitionMedically necessary treatment with a likely side effect of infertility.
    Professional guideline basisThe likelihood of infertility is established by the American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, or American Society of Clinical Oncology.
    Coverage relevanceThe treatment may directly or indirectly cause iatrogenic infertility.
    Iatrogenic Infertility
    DefinitionImpairment of fertility caused by medical treatment affecting the reproductive organs or processes.
    Listed medical causesSurgery, chemotherapy, radiation treatment, gender-affirming treatments, or other medical treatment.
    Policy Summary
    PayerMedStar Family Choice
    PolicyFertility Preservation Services
    Policy CodePolicy 1433
    Change TypeNo material change
    Effective DateN/A
    Last ReviewJul 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization requests for all fertility preservation procedures for medical director review.
    SourceLink
    On This Page
    Fertility Preservation Coverage CriteriaAuthorization, Documentation, and Denial RisksPolicy BackgroundKey Policy Definitions

    Provider and Consent Documentation

    Requests must be submitted by a board-certified reproductive endocrinologist. For a minor, obtain and submit parental consent in accordance with current Maryland Minor Consent Laws.

    • The request must come from the board-certified reproductive endocrinologist performing or responsible for the fertility preservation services.
    • Parental consent is required when the member is a minor.
    Billing Rule

    Storage or Banking Arrangements

    Storage and banking are not covered benefits. Discuss with the member what provisions have been made for storage or banking and document that discussion in the medical record submitted to MFC.

    • The member should be informed that storage and/or banking arrangements are non-covered.
    Denial Risk

    Failure to Meet General Approval Criteria

    Requests may be denied when the member does not meet the general reproductive-age requirement. The member must generally be from puberty through before menopause, except as specifically allowed for ovarian tissue preservation.

    • Puberty is defined as sexual maturity and the capability to reproduce.
    • Menopause is the permanent cessation of menses for at least 12 months in a routine, non-pathologic condition.
    • Apply the ovarian tissue preservation exception only when the separate ovarian tissue criteria are met.
    Denial Risk

    Ineligible GnRH Analog Use

    GnRH agonists may be approved only for specific breast cancer members to decrease the risk of premature ovarian insufficiency. GnRH analogs cannot be used in place of other fertility preservation alternatives.

    • Deny or do not approve requests outside the specified breast cancer population.
    • Deny or do not approve GnRH analog treatment when another fertility preservation alternative is being replaced.
    Denial Risk

    Ovarian Tissue Criteria Not Met

    Ovarian tissue cryopreservation requires either insufficient time for oocyte retrieval or that the member is prepubertal, and the ovarian tissue must not have any malignancy. Requests that fail these requirements may be denied.

    • Document the insufficient time available for oocyte retrieval, or document that the member is prepubertal.
    • Confirm that the ovarian tissue has no malignancy.
    • Ovarian tissue preservation may be considered under the exception to the general reproductive-age requirement only when these criteria are satisfied.
    Denial Risk

    Non-Covered Service Requested

    Do not request or represent excluded services as covered fertility preservation services. Identify the exclusion and advise the member that the service is not covered; storage or banking discussions must also be documented when applicable.

    • Donor sperm and donor oocytes.
    • Intrauterine insemination and in vitro fertilization procedures.
    • Storage or thawing of testicular tissue, including associated charges.
    • Prepubertal testicular tissue cryopreservation, which is investigational.
    • Sperm or oocyte banking/storage and thawing of cryopreserved sperm or oocytes.
    • Medications not approved by the FDA.
    EffectThe treatment-related impairment may result in iatrogenic infertility.
    Standard Fertility Preservation Procedures
    DefinitionProcedures used to preserve fertility.
    Professional guideline basisProcedures must be consistent with professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or the American College of Obstetricians and Gynecologists.
    ExclusionStorage of sperm or oocytes is not included.
    Reproductive Age
    DefinitionThe period from puberty to before menopause.
    PubertyThe point at which an adolescent reaches sexual maturity and becomes capable of reproduction.
    Ovarian tissue preservation exceptionThe definition does not apply where the policy provides an exception for ovarian tissue preservation.
    Menopause
    DefinitionThe routine, non-pathologic condition involving the permanent cessation of menses for at least 12 months.
    Cessation requirementMenses must have permanently ceased.
    Duration requirementThe cessation must continue for at least twelve (12) months.