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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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    Diagnostic infertility evaluation is covered as a medical benefit when performed to establish the cause of infertility. Infertility treatment and sterilization reversal coverage depend on the member’s contract.

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

    No material clinical or coverage changes in this revision.

    2Primary service categories addressed
    Generally excluded

    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.

    Sterilization reversal coverage
    1 yearInfertility definition threshold
    8.5%U.S. infertility rate, 2015–2019
    13.4%U.S. impaired fecundity rate, 2015–2019

    Infertility and Assisted Reproduction Coverage

    Diagnostic Services to Evaluate Potential Infertility

    Diagnostic services are covered when the following condition is met.

    Diagnostic infertility evaluation: The service is performed solely to establish the underlying etiology (cause) of infertility.

    Services to evaluate potential infertility are covered under the Diagnostic Services to Evaluate Potential Infertility table.

    Infertility Treatments

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

    Contract-based infertility treatment eligibility

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

    Sterilization Reversal Services

    Sterilization reversal services may be allowed only under the applicable contract.

    Sterilization reversal eligibility: The member’s contract specifically indicates that the sterilization reversal service is allowed.

    Sterilization reversal services are generally excluded from the member’s infertility benefit. Listing a service in the Sterilization Reversal Services table does not imply coverage.

    Listing a service in the Assisted Fertilization Services tables does not establish coverage. Infertility treatment eligibility is determined by the member’s contract, which prevails for benefit determination. Providers should review the applicable contract before assuming that a listed service is covered.

    Sterilization reversal services are generally excluded from the member’s infertility benefit. These services may be allowed only when specifically indicated in the member’s contract; inclusion in the Sterilization Reversal Services table does not by itself establish coverage.

    Covered and Listed Procedure Codes

    Diagnostic Services to Evaluate Potential Infertility - CPTCPTCovered
    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
    58345Sonohysterography (SIS) or hysterosalpingography; transcervical introduction of fallopian tube catheter for diagnosis and/or establishing patency (any method), with or without hysterosalpingography
    58540Hysteroplasty, repair of uterine anomaly (Strassman type)
    58920Wedge resection or bisection of ovary, unilateral or bilateral
    1–10 of 23
    1/3
    Diagnostic Services to Evaluate Potential Infertility - HCPCSHCPCSCovered
    G0027Semen analysis; presence and/or motility of sperm excluding Huhner
    Q0115Postcoital direct, qualitative examinations of vaginal or cervical mucous
    S3655Antisperm antibodies test (immunobead)
    Ovulation Induction - HCPCSHCPCS
    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
    Ovulation Induction - CPTCPT
    58321Artificial insemination; intra-cervical
    58322Artificial insemination; intra-uterine
    58323Sperm washing for artificial insemination
    89260Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis
    Advanced Reproductive/Fertilization Services - CPTCPT
    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 23
    1/3
    Advanced Reproductive/Fertilization Services - HCPCSHCPCS
    S4035Stimulated intrauterine insemination (IUI), case rate
    S4011In vitro fertilization; including but not limited to 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, case rate
    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
    1–10 of 18
    1/2
    Cryopreserved Embryo Transfers - HCPCSHCPCS
    S4037Cryopreserved embryo transfer, case rate
    S4018Frozen embryo transfer procedure cancelled before transfer
    Intracytoplasmic Sperm Injection (ICSI) or Ovum Microsurgery - CPTCPT
    55870Electroejaculation
    89280Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
    89281Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
    Sterilization Reversal Services - CPTCPT
    55400Vasovasostomy, vasovasorrhaphy
    58750Tubotubal anastomosis
    58760Fimbrioplasty
    58672Laparoscopy, surgical; with fimbrioplasty
    58673Laparoscopy, surgical; with salpingostomy (salpingoneostomy)

    Documentation and Contract Verification

    Documentation Required

    Diagnostic Purpose Must Be Documented

    Document that diagnostic infertility services are performed solely to establish the underlying cause or etiology of infertility.

    Billing Rule

    Verify the Member Contract

    Verify and apply the member’s contract for every infertility service. Listing a service in the Assisted Fertilization Services or Sterilization Reversal Services tables does not establish coverage; the member’s contract prevails.

    Infertility and Assisted Reproduction Context

    Infertility may result from female factors such as pelvic adhesions, ovarian dysfunction, endometriosis, or prior tubal ligation; male factors involving sperm production, function, or transport; combined factors; or unknown causes. The guideline addresses diagnostic evaluation of potential infertility and assisted reproductive services, including procedures that handle eggs or embryos to help achieve pregnancy. Diagnostic services are covered when performed solely to establish the underlying cause of infertility, while infertility treatment coverage depends on the member’s contract. Assisted insemination using partner or donor sperm is distinguished from assisted reproductive technology in this guideline.

    Key Reproductive Health Definitions

    Impaired fecundity
    Physical abilityA woman is physically able to have a child.
    ConceptionShe is unable to conceive a pregnancy.
    Live birthShe is unable to carry a pregnancy to live birth.
    Infertility
    Primary definitionNot being able to get pregnant after one year of unprotected sex.
    Disease or disorderInfertility may result from a disease, interruption, cessation, or disorder of body functions, systems, or organs.
    Reproductive effect
    Policy Summary
    PayerPremera Blue Cross of Washington
    PolicyInfertility and Assisted Reproduction Services
    Policy CodePolicy 4.02.503
    Change TypeNo material change
    Effective DateNovember 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionVerify and apply the member’s contract before assuming infertility treatment is covered.
    SourceLink
    On This Page
    Infertility and Assisted Reproduction CoverageCovered and Listed Procedure CodesDocumentation and Contract VerificationInfertility and Assisted Reproduction ContextKey Reproductive Health Definitions
    Denial Risk

    No Contract Benefit May Result in Denial

    Infertility treatment may be denied when the member’s contract does not include infertility treatment benefits, even if the service appears in a policy table.

    Denial Risk

    Treatment Must Be Contract-Eligible

    After an infertility diagnosis has been established, treatment services may not be covered unless they are eligible under the member’s contract. Confirm contract eligibility before providing or billing treatment.

    Denial Risk

    Sterilization Reversal Generally Excluded

    Sterilization reversal services are generally excluded from the member’s infertility benefit and may be allowed only when specifically indicated in the member’s contract. Verify contract language before providing or billing these services.

    The condition may involve the male or female reproductive tract and prevent conception or the ability to carry a pregnancy to delivery.
    Assisted reproductive technologies
    DefinitionFertility treatments in which eggs or embryos are handled to help achieve pregnancy.
    Treatment examplesExamples include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT).
    Additional examplesOther examples include gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy.
    In vitro fertilization
    Oocyte harvestingOocytes are harvested.
    In-vitro inseminationThe harvested oocytes are inseminated in vitro with sperm.
    CultureThe resulting zygote is cultured.
    TransferThe zygote is transferred to the uterus or fallopian tubes.
    Assisted reproductive technologies (ARTs)
    DefinitionFertility treatments in which eggs or embryos are handled to help achieve pregnancy.
    Transfer techniquesExamples include GIFT, TUFT, NORIF, PROST, TET, and ZIFT.
    Other examplesExamples also include gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy.
    In vitro fertilization (IVF)
    Oocyte collectionOocytes harvested from the female are used.
    In-vitro inseminationThe oocytes are inseminated in vitro with sperm harvested from the male.
    CultureThe resulting zygote is cultured.
    TransferThe cultured zygote is transferred into the uterus or fallopian tubes.
    Assisted insemination
    ProcedureArtificial insemination using sperm from a woman's partner or a sperm donor.
    Partner spermThe sperm may come from the woman's partner.
    Donor spermThe sperm may come from a sperm donor.
    ART classificationAssisted insemination is not included in ART under the policy.