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    v1.0.30
    OpenPayerPolicy UpdatesReproductive Health & FertilityPremera Infertility Coverage Update | OpenPayer
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    CurrentPremera Blue Cross of WashingtonPolicy 4.02.503

    Infertility and Assisted Reproduction Services

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    This guideline explains coverage considerations and coding for infertility diagnostic services, infertility treatments, assisted fertilization services, and sterilization reversal services. Diagnostic evaluation of potential infertility is covered as a medical benefit, while treatment coverage depends on the member's contract and applicable medical-necessity requirements.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInfertility and Assisted Reproduction Services
    Policy CodePolicy 4.02.503
    Change TypeAdministrative/reference update
    Effective DateNovember 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionVerify that the member's contract includes infertility treatment benefits before providing treatment or assisted fertilization services.
    SourceLink
    POLICY UPDATE CHANGES

    The November 2026 interim review updated references while leaving the policy statements unchanged.

    CoveredDiagnostic evaluation coverage

    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.

    Contract-dependentInfertility treatment coverage
    Generally excludedSterilization reversal coverage
    Medicare AdvantagePolicy applicability exclusion

    Coverage Criteria

    Diagnostic Services to Evaluate Potential Infertility

    Diagnostic services to evaluate potential infertility are covered under the medical benefit.

    Diagnostic evaluation

    • Services to evaluate potential infertility are covered as a medical benefit.

    Infertility Treatment for Diagnostic Etiology

    Infertility treatments may be considered medically necessary when performed solely to establish the underlying cause of infertility.

    Establishing infertility etiology

    • The treatment must be performed solely to establish the underlying etiology (cause) of infertility.

    Contract-Dependent Infertility Treatment

    Infertility treatment may also be allowed when the member’s contract provides applicable benefits.

    Contract-dependent treatment circumstances

    • The member has an established infertility diagnosis and the treatment is allowed under the member’s contract.
    • The member is undergoing or scheduled to undergo medical or surgical treatment with a significant likelihood of causing infertility, and the treatment is allowed under the member’s contract.

    Sterilization reversal services are generally excluded from the member’s infertility benefit. Coverage may be allowed only when the member’s contract specifically indicates coverage for the service.

    The inclusion of a service in the Assisted Fertilization Services or Sterilization Reversal Services tables does not, by itself, establish coverage. Coverage is determined by the member’s contract; consult the applicable contract language for benefit determination.

    This medical policy does not apply to Medicare Advantage. Coverage for other medical services remains subject to the limits and conditions of the member’s benefit plan.

    Coded Services

    Diagnostic Services to Evaluate Potential InfertilityCPTCovered
    54500Biopsy of testis, needle (separate procedure)
    54505Biopsy of testis, incisional (separate procedure)
    54800Biopsy of epididymis, needle
    55200Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)
    55300Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral
    55550Laparoscopy, surgical, with ligation of spermatic veins for varicocele
    58340Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
    58345Transcervical introduction of fallopian tube catheter for diagnosis and/or establishing patency, with or without hysterosalpingography
    58540Hysteroplasty, repair of uterine anomaly (Strassman type)
    58559Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
    1–10 of 27
    1/3
    Diagnostic Services to Evaluate Potential InfertilityHCPCSCovered
    G0027Semen analysis; presence and/or motility of sperm excluding Huhner
    Q0115Postcoital direct, qualitative examinations of vaginal or cervical mucous
    S3655Antisperm antibodies test (immunobead)
    Ovulation Inductionmixed
    J0725Injection, chorionic gonadotropin, per 1,000 USP units
    J3355Injection, urofollitropin, 75 IU
    S0122Injection, menotropins, 75 IU
    S0126Injection, follitropin alfa, 75 IU
    S0128Injection, follitropin beta, 75 IU
    S0132Injection, ganirelix acetate, 250 mcg
    S4022Assisted oocyte fertilization, case rate
    S4042Management of ovulation induction, including interpretation of diagnostic tests and studies and non-face-to-face medical management, per cycle
    58321Artificial insemination; intra-cervical
    58322Artificial insemination; intra-uterine
    1–10 of 15
    1/2
    Advanced Reproductive/Fertilization ServicesCPT
    58974Embryo transfer, intrauterine
    76948Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
    89250Culture of oocyte(s)/embryo(s), less than 4 days
    89251Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos
    89253Assisted embryo hatching, microtechniques (any method)
    89254Oocyte identification from follicular fluid
    89255Preparation of embryo for transfer (any method)
    89257Sperm identification from aspiration (other than seminal fluid)
    89258Cryopreservation; embryo(s)
    89259Cryopreservation; sperm
    1–10 of 22
    1/3
    Advanced Reproductive/Fertilization Services; Cryopreserved Embryo Transfers; Intracytoplasmic Sperm Injection (ICSI) or Ovum Microsurgerymixed
    S4011In vitro fertilization; including identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
    S4015Complete in vitro fertilization cycle, not otherwise specified, case rate
    S4016Frozen in vitro fertilization cycle, case rate
    S4017Incomplete cycle, treatment cancelled prior to stimulation, case rate
    S4018Frozen embryo transfer procedure cancelled before transfer
    S4020In vitro fertilization procedure cancelled before aspiration, case rate
    S4021In vitro fertilization procedure cancelled after aspiration, case rate
    S4023Donor egg cycle, incomplete, case rate
    S4025Donor services for in vitro fertilization (sperm or embryo), case rate
    S4026Procurement of donor sperm from sperm bank
    1–10 of 22
    1/3
    Sterilization Reversal ServicesCPTNot Covered
    55400Vasovasostomy, vasovasorrhaphy
    58750Tubotubal anastomosis
    58760Fimbrioplasty
    58672Laparoscopy, surgical; with fimbrioplasty
    58673Laparoscopy, surgical; with salpingostomy (salpingoneostomy)

    Provider and Coverage Actions

    Denial Risk

    Member Contract Controls Coverage

    Verify the member's contract before representing infertility or assisted fertilization services as covered. The existence of a treatment or its listing in an Assisted Fertilization Services table does not establish coverage; services may be denied when infertility benefits are not included.

    • The member contract prevails if it differs from this guideline or the service tables.
    • Refer to the member contract language for the benefit determination.
    Denial Risk

    Sterilization Reversal Generally Excluded

    Treat sterilization reversal services as generally excluded from the member's infertility benefit. They may be allowed only when indicated in the member's contract, and listing a reversal code does not imply coverage.

    • Verify the contract before billing or scheduling sterilization reversal services.
    • Sterilization reversal codes include CPT 55400, 58750, 58760, 58672, and 58673.

    Infertility and Assisted Reproduction Background

    Infertility is the inability to conceive or to carry a pregnancy to delivery. Causes may involve female factors, such as pelvic adhesions, ovarian dysfunction, endometriosis, or prior tubal ligation; male factors, including abnormalities in sperm production, function, or transport or prior vasectomy; combined female and male factors; or unexplained causes. Assisted reproductive technologies may include in vitro fertilization, gamete or embryo cryopreservation, donor gametes, and procedures that transfer gametes, zygotes, or embryos.

    Key Definitions

    Impaired fecundity
    Physical abilityA woman is physically able to have a child.
    ConceptionUnable to conceive a pregnancy.
    Pregnancy outcomeUnable to carry a pregnancy to live birth.
    Infertility
    Primary definitionNot being able to get pregnant (conceive) after one year of unprotected sex.
    Underlying conditionThe result of a disease, interruption, cessation, or disorder of body functions, systems, or organs of the male or female reproductive tract.
    Effect
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInfertility and Assisted Reproduction Services
    Policy CodePolicy 4.02.503
    Change TypeAdministrative/reference update
    Effective DateNovember 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionVerify that the member's contract includes infertility treatment benefits before providing treatment or assisted fertilization services.
    SourceLink
    On This Page
    Coverage CriteriaCoded ServicesProvider and Coverage ActionsInfertility and Assisted Reproduction BackgroundKey Definitions
    Note

    Post-Diagnosis Treatment Is Contract-Dependent

    Infertility treatments are medically necessary when performed solely to establish the underlying cause of infertility. Once an infertility diagnosis has been established, however, subsequent treatment remains dependent on the member's contract.

    • Confirm contract benefits before proceeding with post-diagnosis infertility treatment.
    • Contract-dependent treatment may also apply to members undergoing or scheduled for medical or surgical treatment with a significant likelihood of causing infertility.
    The condition prevents conception of a child or the ability to carry a pregnancy to delivery.
    Assisted reproductive technology
    Treatment typeFertility treatments in which eggs or embryos are handled to help achieve pregnancy.
    Eggs or embryosThe treatment involves handling eggs or embryos.
    Excluded procedureAssisted insemination (artificial insemination) using sperm from either a woman's partner or a sperm donor is not included.
    Assisted reproductive technologies (ARTs)
    DefinitionFertility treatments in which eggs or embryos are handled to help achieve pregnancy.
    Named examplesExamples include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), transuterine fallopian transfer (TUFT), natural oocyte retrieval with intravaginal fertilization (NORIF), pronuclear stage tubal transfer (PROST), and tubal embryo transfer (TET).
    Additional examplesOther examples include zygote intrafallopian transfer (ZIFT), gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy.
    In vitro fertilization (IVF)
    OocytesOocytes are harvested from the female.
    InseminationThe harvested oocytes are inseminated in vitro with sperm harvested from the male.
    CultureFollowing fertilization, the resulting zygote is cultured.
    TransferThe zygote is ultimately transferred back into the female's uterus or fallopian tubes.
    Assisted insemination
    DefinitionArtificial insemination using sperm from a woman's partner or a sperm donor.
    Sperm sourceSperm may come from either the woman's partner or a sperm donor.
    Distinction from ARTAssisted insemination is not included in assisted reproductive technologies (ARTs).