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    v1.0.30
    OpenPayerPolicy UpdatesReproductive Health & FertilityPremera Infertility Coverage Update | OpenPayer
    Ask Trek AI about this page
    CurrentPremera Blue Cross of WashingtonPolicy 4.02.503

    Infertility and Assisted Reproduction Services

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    Coverage considerations and coding for diagnostic infertility services, infertility treatments, assisted reproductive services, and sterilization reversal services. Treatment coverage depends on the member's contract.

    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInfertility and Assisted Reproduction Services
    Policy CodePolicy 4.02.503
    Change TypeAdministrative/reference updateno material change
    Effective DateNovember 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionVerify the member's contract before assuming infertility treatment is covered.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 yearInfertility definition

    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.

    8.5%
    Infertility rate
    13.4%Impaired fecundity
    4.02.04Replaced policy
    4ART components described
    NoneFDA-approved or cleared ART devices/tests

    Coverage Criteria

    Diagnostic Services to Evaluate Potential Infertility

    Covered when performed solely to establish the underlying cause of infertility.

    Diagnostic infertility evaluation: Services to evaluate potential infertility are covered when performed solely to establish the underlying etiology (cause) of infertility.

    Infertility Treatment

    Infertility treatment may be allowed when the member’s contract provides the benefit.

    Qualifying infertility treatment context: Infertility treatment may be allowed after an infertility diagnosis has been established, or for a member undergoing or scheduled to undergo medical or surgical treatment with a significant likelihood of causing infertility.

    Coverage remains dependent on the member’s contract.

    Sterilization Reversal Services

    Coverage is subject to the member’s contract.

    Sterilization reversal services are generally excluded from the member’s infertility benefit and may be allowed only if indicated in the member’s contract.

    Listing a sterilization reversal service in the table does not imply coverage; the member’s contract prevails.

    Sterilization reversal services are generally excluded from the member’s infertility benefit. Coverage may be allowed only when indicated by the member’s contract; listing a service in the Sterilization Reversal Services table does not imply coverage.

    This medical policy does not apply to Medicare Advantage. Coverage determinations should be based on the applicable member benefit materials.

    Covered and Non-Covered Codes

    Diagnostic Services to Evaluate Potential InfertilitymixedCovered
    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 (any method), with or without hysterosalpingography
    58540Hysteroplasty, repair of uterine anomaly (Strassman type)
    58555Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
    1–10 of 30
    1/3
    Ovulation InductionmixedCovered
    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 (interpretation of diagnostic tests and studies, non face-to-face medical management of the patient), per cycle
    58321Artificial insemination; intra-cervical
    58322Artificial insemination; intra-uterine
    1–10 of 15
    1/2
    Advanced Reproductive/Fertilization Services, Cryopreserved Embryo Transfers, and Intracytoplasmic Sperm Injection (ICSI) or Ovum MicrosurgerymixedCovered
    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 44
    1/5
    Sterilization Reversal ServicesCPTNot Covered
    55400Vasovasostomy, vasovasorrhaphy
    58750Tubotubal anastomosis
    58760Fimbrioplasty
    58672Laparoscopy, surgical; with fimbrioplasty
    58673Laparoscopy, surgical; with salpingostomy (salpingoneostomy)

    Provider Documentation and Benefit Checks

    Documentation Required

    Document Diagnostic Purpose

    Document that infertility diagnostic services are performed solely to establish the underlying etiology (cause) of infertility. Services to evaluate potential infertility are covered as a medical benefit when used for this diagnostic purpose.

    Documentation Required

    Document Qualifying Clinical Context

    Document the established infertility diagnosis or the applicable medical or surgical treatment context. Infertility treatment may also be considered for members undergoing or scheduled to undergo treatment with a significant likelihood of causing infertility.

    • Record the established infertility diagnosis when infertility has been confirmed.
    • If no diagnosis has been established, document the relevant medical or surgical treatment and its significant likelihood of causing infertility.

    Unsupported block type: billing_rule

    Infertility Background

    Infertility may result from female factors, including pelvic adhesions, ovarian dysfunction, endometriosis, or prior tubal ligation; male factors, including abnormalities in sperm production, function, or transport, or prior vasectomy; combined factors; or unknown causes.

    Reproductive Health Definitions

    Impaired fecundity
    Applies toA woman who is physically able to have a child
    DefinitionUnable to conceive a pregnancy
    Additional limitationUnable to carry a pregnancy to live birth
    Infertility
    TimeframeUnable to get pregnant after one year of unprotected sex
    Medical descriptionA disease, interruption, cessation, or disorder of the male or female reproductive tract
    ResultPrevents conception of a child or the ability to carry a pregnancy to delivery
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInfertility and Assisted Reproduction Services
    Policy CodePolicy 4.02.503
    Change TypeAdministrative/reference updateno material change
    Effective DateNovember 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionVerify the member's contract before assuming infertility treatment is covered.
    SourceLink
    On This Page
    Coverage CriteriaCovered and Non-Covered CodesProvider Documentation and Benefit ChecksInfertility BackgroundReproductive Health Definitions
    Denial Risk

    Sterilization Reversal Generally Excluded

    Sterilization reversal services are generally excluded from the member’s infertility benefit. They may be allowed only when indicated in the member’s contract, and a listing in the Sterilization Reversal Services table does not imply coverage.

    • Verify contract-specific coverage before billing sterilization reversal services.
    • Relevant services include CPT 55400 (vasovasostomy/vasovasorrhaphy), 58750 (tubotubal anastomosis), 58760 (fimbrioplasty), 58672 (laparoscopy with fimbrioplasty), and 58673 (laparoscopy with salpingostomy/salpingoneostomy).
    • If the member’s contract differs from the table, the member’s contract prevails.
    Assisted reproductive technologies
    DefinitionFertility treatments in which eggs or embryos are handled to help achieve pregnancy
    Included materialsEggs or embryos
    Not includedAssisted insemination using sperm from either a woman's partner or a sperm donor
    Assisted reproductive technologies (ART)
    DefinitionFertility treatments in which eggs or embryos are handled to help achieve pregnancy
    ExamplesIn 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 examplesZygote intrafallopian transfer (ZIFT), gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy
    Broad componentsOocyte harvesting, sperm collection, in vitro laboratory procedures, and implantation
    Assisted insemination
    Sperm sourceSperm from a woman's partner or a sperm donor
    ClassificationAssisted insemination, also called artificial insemination, is distinguished from assisted reproductive technologies (ART)
    ART definitionAssisted insemination is not included in the policy's definition of ART