CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Infertility Diagnosis and Assisted Reproductive Technology Coverage

Governs coverage and medical necessity criteria for infertility diagnosis and assisted reproductive technology services for Neighborhood Health Plan of Rhode Island members, including eligibility, authorized services, limits, and exclusions.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyInfertility Diagnosis and Assisted Reproductive Technology Coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 14, 2024

Key ActionSubmit prior authorization prospectively using Neighborhood's Infertility Prior Authorization form with required diagnostic testing and prior cycle history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8authorized total infertility cycles per lifetime

3maximum IVF cycles

1maximum donor egg cycles

3maximum FET cycles

RIGL 27-20-20State mandate reference

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Coverage & Medical Necessity Criteria

General medical necessity and service-specific criteria

Covered when ALL of the following are met

General eligibility: Member meets the policy definition of infertility and the member with diagnosed infertility is the recipient of the intended infertility services.

Provider and location: Members must receive infertility services at a Neighborhood Health Plan of Rhode Island contracted provider.

Authorized services and lifetime limits: Up to eight (8) total infertility cycles per lifetime. Includes: (1) Clomiphene or aromatase inhibitor cycles with or without IUI; (2) Ovulation stimulation with gonadotropins with or without IUI; (3) In‑vitro fertilization (IVF) — maximum 3 lifetime cycles; (4) Frozen embryo transfer (FET) — maximum 3 lifetime cycles; (5) Donor egg — maximum 1 lifetime cycle.8 cycles lifetime; IVF≤3; FET≤3; donor egg≤1

IVF specific criteria: Authorization of IVF requires one of the following: failure of ≥3 cycles of clomiphene citrate or gonadotropin ovarian hyperstimulation; OR natural/artificial insemination would not be expected to be effective for reasons including severe male factor, tubal factor, advanced (stage III/IV) endometriosis, failure to conceive after pelvic surgery with restored anatomy, infertility related to ectopic pregnancy, certain hydrosalpinx, or inadvertent ovarian hyperstimulation in a stimulated IUI cycle. Severe male factor is defined as either: <10 million total motile sperm/ejaculate (pre‑wash) or <3 million total motile sperm (post‑wash) on two separate semen analyses at least 2 weeks apart; OR poor (<50%) or failed fertilization in a current/previous cycle; OR 1% normal forms (Strict Kruger morphology).

Frozen embryo transfer sequencing: Before proceeding to the next fresh ART cycle, use FET cryopreserved embryos if ≥3 cryopreserved embryos of similar developmental stage are available (≥4 if woman is ≥35 years).3 embryos; 4 if age≥35

ICSI: Intracytoplasmic sperm injection (ICSI) is generally appropriate and will be approved when severe male factor exists as defined in the policy.

Donor egg coverage: Donor egg cycles may be covered for women with premature menopause or premature ovarian failure with onset ≤40 years and follicle stimulating hormone (FSH) > 15 mIU on cycle day 3 or 10. Women with abnormal FSH after age 40 are not eligible for donor egg coverage.FSH > 15 mIU on cycle day 3 or 10; onset ≤40

Iatrogenic infertility / fertility preservation: Standard fertility preservation services are covered for Commercial (HBE) plans when a medically necessary treatment may directly or indirectly cause iatrogenic infertility; services follow established professional guidelines. Donor recruitment, compensation/stipend and medications are not covered.

Applies to Commercial (HBE) plans only.

Coverage excludes services that are experimental or provided to members who do not meet the policy definition of infertility. Also excluded are infertility services that are performed to reverse or compensate for an intentionally produced infertility, procurement of frozen donor oocytes, costs associated with donor recruitment or compensation, and the costs of surrogacy (including drugs for implantation, embryo transfer and cryopreservation, use of donor eggs, and maternity care when the surrogate is not a member).

Retroactive coverage requests for procedures already performed may not be covered; prior authorization and documentation requirements must be met to establish medical necessity before services are rendered whenever the policy requires prospective review.

Donor sperm and associated laboratory services are not covered when the member’s partner does not have a diagnosed male factor infertility. Costs related to donor recruitment and compensation, and procurement of frozen donor oocytes are also excluded under this policy.

Standard fertility preservation for iatrogenic infertility is covered for Commercial (HBE) plans when medically necessary, but coverage explicitly excludes donor recruitment/compensation and medications; this distinction does not alter the exclusion for donor sperm or related lab services absent documented male factor.

Coding and Billing

Provider Requirements & Authorization

Prior Authorization

Prior authorization required

Authorization is required for some diagnostic procedures and all infertility treatment services; requests must be submitted using Neighborhood's Infertility Prior Authorization form and submitted prospectively where required.

Use Neighborhood's Infertility Prior Authorization form for all requests.
Some diagnostic procedures for establishing infertility require prior authorization.

Step Therapy

IVF step therapy / eligibility

Authorization for in‑vitro fertilization (IVF) requires documentation that the woman has failed three or more cycles of clomiphene citrate or gonadotropin ovarian hyperstimulation, unless criteria such as severe male factor, tubal factor, or advanced endometriosis make insemination unlikely to be effective.

Severe male factor examples and definitions are specified in policy (e.g., total motile sperm <10 million pre‑wash or <3 million post‑wash on two specimens).

Background

Infertility is defined for policy purposes by age, partner status, and clinical context (for example: inability to conceive after 1 year of unprotected intercourse for women ≤35, after 6 months for women >35, and specific definitions for members without a male partner or with prior miscarriage). Evaluation to establish the diagnosis typically includes female hormonal testing (e.g., FSH, estradiol, TSH), ovarian reserve assessment, imaging (hysterosalpingography, hysteroscopy, laparoscopy as indicated), and a semen analysis for the male partner.

Before authorization of assisted reproductive services, providers must document diagnostic testing and previous treatment attempts consistent with the policy criteria (for example, step-therapy requirements for IVF). Standard fertility preservation related to iatrogenic infertility is covered for Commercial (HBE) plans when treatment is likely to impair future fertility, but donor recruitment, compensation, and medications remain excluded.

Key Definitions

Infertility — age‑stratified definitions (women with a male partner)

Women ≤35 with a male partnerInfertility is inability to conceive after 1 year of unprotected intercourse with exposure to sperm.

Women >35 with a male partnerInfertility is inability to conceive after 6 months of unprotected intercourse with exposure to sperm.

Women with prior miscarriageInfertility is failure to conceive or sustain a pregnancy to delivery for 1 year.

Women without a male partnerInfertility is inability to conceive after six intrauterine cycles using normal-quality donor sperm performed by a qualified specialist.

Iatrogenic infertilityImpairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.