Infertility and Assisted Reproduction Services
Policy governing coverage and coding for diagnostic evaluation, assisted fertilization (including ART/IVF, IUI), ovulation induction, cryopreservation, and sterilization reversal services; applies to members whose contracts include infertility benefits and to providers submitting claims to Premera Blue Cross.
No material clinical or coverage changes in this revision.
Coverage Criteria for Infertility and Assisted Reproduction Services
General medical necessity guidance for infertility treatments
Covered when ALL of the following are met (as applicable and per member contract):
Coverage depends on member contract
Subject to member contract
Sterilization reversal procedures are generally excluded from the member infertility benefit. These services may only be considered when the member's specific contract explicitly indicates coverage; inclusion of a sterilization reversal code in the policy tables does not guarantee payment. Providers and members should consult the member benefit booklet or contact member services to confirm whether sterilization reversal is covered for a given member.
This medical policy does not apply to Medicare Advantage plans. Coverage determinations, benefit limits, and prior authorization requirements for Medicare Advantage enrollees are governed by the member's specific Medicare Advantage plan documents and should be verified with the plan or member services.
Codes and Billing Categories
| 54500 | Biopsy of testis, needle (separate procedure) |
| 54505 | Biopsy of testis, incisional (separate procedure) |
| 54800 | Biopsy of epididymis, needle |
| 55200 | Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) |
| 55300 | Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral |
| 55550 | Laparoscopy, surgical, with ligation of spermatic veins for varicocele |
| 58340 | Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography |
| 58345 | Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography |
| 58350 | Chromotubation of oviduct, including materials |
| 58540 | Hysteroplasty, repair of uterine anomaly (Strassman type) |
| J0725 | Injection, chorionic gonadotropin, per 1,000 USP units |
| J3355 | Injection, urofollitropin, 75 IU |
| S0122 | Injection, menotropins, 75 IU |
| S0126 | Injection, follitropin alfa, 75 IU |
| S0128 | Injection, follitropin beta, 75 IU |
| S0132 | Injection, ganirelix acetate, 250 mcg |
| S4022 | Assisted oocyte fertilization, case rate |
| S4042 | Management of ovulation induction, per cycle |
| 58321 | Artificial insemination; intra-cervical |
| 58322 | Artificial insemination; intra-uterine |
| 58970 | Follicle puncture for oocyte retrieval, any method |
| 58974 | Embryo transfer, intrauterine |
| 76948 | Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation |
| 89250 | Culture of oocyte(s)/embryo(s), less than 4 days |
| 89251 | Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture |
| 89253 | Assisted embryo hatching, microtechniques |
| 89254 | Oocyte identification from follicular fluid |
| 89255 | Preparation of embryo for transfer |
| 89257 | Sperm identification from aspiration (other than seminal fluid) |
| 89258 | Cryopreservation; embryo(s) |
Provider Requirements, Prior Authorization, and Billing Guidance
Prior authorization may be required for advanced/reproductive services
Infertility treatment services listed in the Assisted Fertilization and Advanced Reproductive Services tables (for example, in vitro fertilization case rates, stimulated IUI case rates, cryopreserved embryo transfer case rates, and donor services) may require prior authorization per the member’s contract.
Verify benefit and prior authorization requirements
Verify member-specific benefits and whether prior authorization is required before providing infertility treatments; coverage and PA requirements are determined by the member’s contract and benefit limits.
- If differences exist between the tables and the member’s contract, the member’s contract prevails.
- Contact member services or review the member benefit booklet to confirm PA and coverage.
Step therapy not specified
This policy does not specify any step therapy sequences for infertility treatments; no mandatory stepwise medication or procedure sequence is defined here.
Provider: confirm contract-based coverage and authorization
Providers must be aware that coverage decisions depend on contract language and benefit limits; confirm coverage and authorization requirements with the payer prior to treatment.
Document infertility diagnosis and contract-based indication
Document the diagnostic evaluation that establishes an infertility diagnosis and record the contract-based indication for treatment; coverage of infertility treatments depends on the documented indication and member contract language.
- Include diagnostic findings that meet the policy’s requirement that an infertility diagnosis be established before infertility treatments may be allowed.
- Document when treatments are for fertility preservation related to gonadotoxic therapy, if applicable.
Verify member benefit booklet
Consult the member benefit booklet or contact a customer service representative to determine whether a specific infertility service or supply is covered for the member.
- Member contracts differ; the member benefit booklet prevails when there is a discrepancy with the policy tables.
Coverage contingent on member contract
Coverage for assisted fertilization, sterilization reversal, and other infertility services is contingent on the member’s contract; services may be denied if the contract does not include infertility benefits or excludes specific services.
- Listing of a service in the policy tables does not imply coverage; refer to the member contract for benefit determination.
Benefit limitations may trigger denial
Coverage is subject to the limits and conditions of the member benefit plan; applicable benefit limitations in the member benefit booklet or via member services may result in denial of services.
- Always consult the member benefit booklet or contact member services to determine any applicable limitations or conditions that could trigger denial.
Background and Context
Infertility is defined as the inability to conceive or to carry a pregnancy to delivery and can result from female, male, combined, or unexplained causes. It is typically established after an appropriate diagnostic evaluation when a couple or individual has not achieved pregnancy following a standard period of unprotected intercourse. Diagnostic testing evaluates factors such as semen quality, ovulatory function, tubal patency, and uterine anatomy to identify correctable causes.
Assisted reproductive technologies (ART) are treatments in which gametes or embryos are handled in the laboratory and include procedures such as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and cryopreservation of oocytes, sperm, or embryos. ART and related services are used when diagnostic evaluation identifies causes not amenable to simpler interventions or when fertility preservation is needed prior to gonadotoxic therapy.
Epidemiologic estimates indicate that a notable minority of reproductive-aged women experience infertility or impaired fecundity; prevalence estimates cited in national data place infertility and impaired fecundity in the low-to-mid double-digit percent range. Because ART techniques and related laboratory services are complex and evolving, there are no FDA-cleared medical devices or diagnostic tests specifically for ART that determine regulatory status of these procedures.
Key Definitions
Policy Revision History
New policy added to Reproduction section; diagnostic services to evaluate potential infertility covered under standard medical benefit while infertility treatments noted as not covered under a standard benefit plan.
CPT code 89322 added to the list of codes covered for services to evaluate potential infertility.
HCPCS code S4040 added to the policy under 'Services to Evaluate Potential Infertility'.
Correction moved HCPCS code S4040 from 'Services to Evaluate Potential Infertility' to 'Infertility Treatments or Assisted Reproductive Services' coding section.
CPT codes 0058T, 0357T and 89398 added to the 'Infertility Treatments or Assisted Reproductive Services' coding section.
Multiple CPT codes and HCPCS code S3655 added to the 'Services to Evaluate Potential Infertility' coding section.
Annual review clarified that testing to evaluate potential infertility is covered under a standard medical benefit and treatment coverage depends on member contract; coding tables reorganized for clarity.
Policy updated to indicate sterilization reversals may be allowed dependent on member benefit; supporting codes added.
Annual review; moved to new format and updated infertility statistics and reference; no changes to coverage guidelines.
Annual review added clarifying statement permitting fertility preservation for members undergoing treatments likely to cause infertility and updated infertility statistics.
Coding update removed CPT codes 89290 and 89291 and added CPT codes 54800, 89337, and 0357T.
Annual review; guideline statement unchanged.
Coding revisions moved several CPT/HCPCS codes between sections (e.g., S3655, Q0115, 89325, 89329) to better reflect diagnostic versus treatment services.
Annual review; benefit coverage guideline reviewed and guideline statements unchanged; removed several CPT codes.
Annual review; benefit coverage guideline reviewed and guideline statements unchanged.
Annual review with reference added and title changed from 'Infertility and Reproductive Services' to 'Infertility and Assisted Reproduction Services'.
Coding update deleted expired CPT codes 0357T and 0058T and corrected labeling for S4013 as HCPCS.
Annual review; benefit coverage guideline reviewed and references updated; guideline statements unchanged.
Annual review; benefit coverage guideline reviewed and references updated; guideline statements unchanged.
Minor update added BCBSA reference policy 4.02.04 Reproductive Techniques.
Annual review; benefit guideline reviewed and guideline statements unchanged (approved October 13, 2025).
Annual review approved May 11, 2026; benefit coverage guideline reviewed and reference updated; guideline statements unchanged.
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