CurrentmhnPolicy HNCA.CP.MP.130

Fertility Preservation (PDF)

Defines medical necessity criteria for fertility preservation procedures for adolescents and adults whose medically necessary treatment is likely to cause infertility, and lists procedures considered insufficiently supported by evidence. Includes coding guidance and procedures considered not medically necessary/insufficient evidence.

Policy Summary

Payermhn

PolicyFertility Preservation (PDF)

Policy CodePolicy HNCA.CP.MP.130

Change TypeRevisions and coding updates

Effective Date

Next Review Date

Key ActionFor female reproductive systems age ≥ 40 requesting oocyte retrieval, the treating provider must document evaluation of age, infertility risk factors, measure of ovarian reserve, and justify that use of the enrollee's own oocytes is a viable strategy.

SourceLink

POLICY UPDATE CHANGES

Expanded criteria to include iatrogenic causes of infertility and added ICD-10 codes D27.0, D27.1, N70.03, N70.13, N83.51.

Removed/added multiple CPT and HCPCS codes across revisions (examples: removed CPT 0375T; added CPTs 00922, 53899, 55899, 55870; added HCPCS S4028).

Policy statements clarified to specify that fertility risk is from medically necessary treatment.

Added explicit listing of procedures considered insufficient evidence (e.g., ovarian suppression with GnRH analogs; testicular suppression; reimplantation of testicular tissue).

Administrative and language updates (gender-neutral language, minor background wording) and annual literature/reference updates.

3Female procedures listed as medically necessary

1Female procedures listed as insufficient evidence

Coverage Summary

Scope: This policy defines medical necessity criteria for fertility preservation in adolescents and adults whose medically necessary treatment is likely to cause infertility (excluding voluntary sterilization), and includes coding guidance and procedures considered not medically necessary or insufficient evidence. Coverage stance: mixed — specific procedures are covered when criteria are met and other procedures are considered unsupported due to insufficient evidence. Affected populations: adolescents and adults (those with female reproductive systems and those with male reproductive systems). Generally covered when criteria are met: for people with a female reproductive system — ovarian stimulation and retrieval of oocytes, ovarian tissue retrieval (when ovarian tissue is free from malignancy and there is insufficient time for oocyte retrieval or the patient is prepubertal), and ovarian transposition (oophoropexy); for people with a male reproductive system — sperm extraction and retrieval procedures. Generally unsupported / insufficient evidence: ovarian suppression with GnRH agonists/antagonists for females, and testicular suppression with GnRH agonists/antagonists and reimplantation/grafting of human testicular tissue for males.

Key statistics from brief.stats

Female - medically necessary proceduresOvarian stimulation and retrieval of oocytes; ovarian tissue retrieval (if tissue free of malignancy and if insufficient time for oocyte retrieval or prepubertal); ovarian transposition (oophoropexy)

Female - insufficient evidenceOvarian suppression with GnRH agonist or antagonists

Male - medically necessary proceduresSperm extraction and retrieval procedures

Male - insufficient evidenceTesticular suppression with GnRH agonist or antagonists; reimplantation/grafting of human testicular tissue

Policy referencesReferences include ASRM, ASCO, NCCN, ACOG guidelines cited in policy

Medical-Necessity Criteria

Coding Guidance

Relevant CPT / HCPCS / other codes listed in policymixed

00840	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified.
00922	Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles.
53899	Unlisted procedure, urinary system.
55870	Electroejaculation.
55899	Unlisted procedure, male genital system.
58825	Transposition, ovary(s).
58970	Follicle Puncture for oocyte retrieval, any method.
76856	Ultrasound, pelvic (nonobstetric), real time with image documentation; complete.
76948	Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation.
82670	Estradiol; total

1–10 of 22

1/3

CPT Codes that do not support medical necessityCPTNot Covered

53899	Unlisted procedure, urinary system.
55899	Unlisted procedure, male genital system.
89398	Unlisted reproductive medicine laboratory procedure

Coding updates: the policy history documents multiple coding table changes across revisions (2019–2025), including deletions and additions of CPT and HCPCS codes (examples noted in the log: removal of CPT 0375T and addition of CPTs such as 00922, 53899, 55899, 55870 and addition of HCPCS S4028). Refer to the policy code table and the latest revision log for the current, authoritative list of included and excluded CPT/HCPCS codes.

Provider Actions

Documentation Required

Documentation for female patients ≥ age 40 requesting oocyte retrieval

For female reproductive systems aged 40 or older who request retrieval of their own oocytes, the treating provider must document that they evaluated the patient’s age, infertility risk factors, and a measure of ovarian reserve, and must justify that use of the member/enrollee’s own oocytes is a viable strategy for attempting future conception.

Prior Authorization

Coverage conditional on benefit plan contract

Coverage for fertility preservation procedures is conditional on the procedure being a covered benefit under the member’s/enrollee’s benefit plan contract and on the treatment causing the fertility risk being medically necessary. Voluntary sterilization is excluded.

Background & Evidence

Background: Fertility preservation is indicated for patients who will undergo gonadotoxic treatments (chemotherapy, radiation, surgical resection, bilateral oophorectomy) or other iatrogenic causes that may transiently or permanently impair fertility. National society guidance (ASRM, ASCO, NCCN, ACOG) informs the policy: oocyte and embryo cryopreservation are established methods when there is adequate time for ovarian stimulation and retrieval; ovarian tissue cryopreservation is increasingly accepted and considered an established option for selected patients (including prepubertal patients or when there is insufficient time for stimulation), though data on long-term efficacy and safety are still evolving and certain patient groups (e.g., leukemia) require caution. Guidelines note that ovarian transposition can be used to reduce gonadal radiation exposure when appropriate. Use of GnRH analogs (ovarian or testicular suppression) remains controversial and is considered of insufficient evidence to support as a fertility preservation method.

Guideline/Source	Summary
ASRM committee opinion (2019)	States ovarian tissue cryopreservation is considered established in selected patients but data on efficacy and outcomes are limited; use of GnRH analogs for ovarian protection during chemotherapy remains controversial.
ASCO guideline	Recommends discussing fertility preservation with all patients of reproductive age before treatment; sperm cryopreservation established for males; embryo and oocyte cryopreservation established for females; ovarian tissue cryopreservation evidence insufficient but evolving; GnRH analogs insufficient evidence.
NCCN	Recommends oocyte/embryo cryopreservation if therapy can be delayed ~3 weeks; ovarian tissue cryopreservation promising when time insufficient or patient is prepubertal; evidence for GnRH agonist protection controversial and not considered fertility preservation.
ACOG	Supports offering oocyte or embryo cryopreservation when adequate time and safe stimulation exist; notes ovarian tissue extraction/cryopreservation have had some success with auto transplantation; GnRH agonists/antagonists lack conclusive evidence for efficacy in fertility preservation.
Policy clinical evidence summary	Policy cites national society guidance that oocyte and embryo cryopreservation are established methods; ovarian tissue cryopreservation increasingly accepted for prepubertal patients or when time is insufficient; GnRH analogs for ovarian or testicular suppression are of insufficient evidence.

Definitions: Medically necessary treatment — treatment that is medically necessary per the member's/enrollee's benefit plan contract and that places the member at risk for infertility (policy excludes voluntary sterilization).

Revision History

9/16 (Approval 10/16)revised

Adopted from Health Net NMP512; Expanded criteria to include iatrogenic causes of infertility and added ICD-10 codes D27.0, D27.1, N70.03, N70.13, N83.51.

04/20 (code deleted 1/1/20)revised

Removed CPT 0375T (code deleted 1/1/20) as part of coding updates.

02/21revised

Revised CPT descriptions and replaced 'experimental/investigational' verbiage with descriptive language in policy statements III and IV.