Currentpriority healthPolicy N/A

Recurrent pregnancy loss

Defines Priority Health coverage stance for therapies and tests used in evaluation and treatment of recurrent pregnancy loss and identifies services considered ineffective, experimental/investigational, and coding that may support medical necessity for RPL.

Policy Summary

Payerpriority health

PolicyRecurrent pregnancy loss

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 24, 2023

Next Review DateN/A

Key ActionIf prior authorization is required, submit a request demonstrating medical necessity per the Priority Health Provider Manual.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2therapies listed as ineffective / not medically necessary

3tests/studies listed as experimental/investigational

N96ICD-10 code supporting medical necessity

88184-88189, 0607U-0608UExample CPT/HCPCS codes referenced

Coverage criteria and determinations

Ineffective / Not Medically Necessary Treatments

Policy Summary

Payerpriority health

PolicyRecurrent pregnancy loss

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 24, 2023

Next Review DateN/A

Key ActionIf prior authorization is required, submit a request demonstrating medical necessity per the Priority Health Provider Manual.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Experimental / Investigational Tests

Tests/studies considered experimental and investigational:

Experimental / Investigational tests: Reproductive immunophenotype testing (CD3+, CD4+, CD5+, CD8+, CD16+, CD19+, CD56+), Cytokine polymorphisms analysis (Th1/Th2 intra-cellular cytokine ratio), AND Natural Killer (NK) cell testing are considered experimental and investigational for evaluation of recurrent pregnancy loss.

Listed as experimental/investigational per policy.

Coverage under this policy is subject to the member's specific benefits and the applicable plan documents. Where group-specific policy or an individual insurance policy document, Evidence of Coverage (EOC), Medicare/CMS determinations, or state-mandated benefits conflict with this policy, the provisions of the applicable plan document or governing authority will supersede this policy. Providers should consult the member’s plan type (HMO/EPO, POS, PPO, ASO) and any relevant plan documents for specific coverage determinations.

Coding that may support medical necessity

ICD-10 Codes that may support medical necessityICD-10

N96	Recurrent pregnancy loss

Additional ICD-10 / pregnancy supervision codesICD-10

O09.211-O09.219	Supervision of pregnancy with history of pre-term labor (range given)
O09.291-O09.299	Supervision of pregnancy with other poor reproductive or obstetric history (range given)
O26.20-O26.23	Pregnancy care for patient with recurrent pregnancy loss (range given)
Z31.441	Encounter for testing of male partner of patient with recurrent pregnancy loss

CPT/HCPCS Codes (list not inclusive)mixed

88184	Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker
88185	Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker
88187	Flow cytometry, interpretation; 2 to 8 markers
88188	Flow cytometry, interpretation; 9 to 15 markers
88189	Flow cytometry, interpretation; 16 or more markers
0607U	Reproductive medicine (endometrial microbiome assessment), real-time PCR analysis for 31 bacterial DNA targets from endometrial biopsy, reported with quantified levels of bacterial presence and targeted treatment recommendations
0608U	Reproductive medicine (endometrial microbiome assessment), real-time PCR analysis for 10 bacterial DNA targets from endometrial biopsy, reported with quantified levels of bacterial presence and targeted treatment recommendations

Provider requirements and billing actions

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for certain drugs, services, and procedures. When prior authorization is required, providers must submit a request that demonstrates the drug, service, or procedure is medically necessary. Refer to the Priority Health Provider Manual for detailed submission instructions and documentation expectations.

Submit prior authorization requests through the usual Priority Health channels and include all supporting clinical documentation that demonstrates medical necessity.
If a prior authorization is required but not obtained, services may be denied or subject to retrospective review.

Note

Product Applicability

Coverage is subject to the member's specific benefits and plan documents. This policy applies to insured HMO/EPO, POS, and PPO plans; for ASO (self-funded) plans, the employer's plan document governs. If there is a conflict between this policy and a member’s plan document (including state-mandated benefits), the plan document will supersede this policy.

HMO/EPO: Applies to insured HMO/EPO plans.
POS: Applies to insured POS plans.
PPO: Applies to insured PPO plans; consult individual plan documents for state-mandated benefits.
ASO: For self-funded plans, consult the employer’s plan document; that document governs in case of conflict.

Documentation Required

Prior Authorization and Plan Applicability

Submit prior authorization requests and questions according to the member's product rules. Demonstration of medical necessity must align with the criteria in this policy and any applicable product-specific requirements. When filing a PA for members of self-funded (ASO) plans, verify the employer plan's requirements as those provisions take precedence.

Use the member’s specific benefit plan to determine coverage before submitting a PA.
Document how requested services meet the medical necessity criteria outlined in this policy.
For ASO members, include any employer-specific authorization forms or documentation required by the plan.

Denial Risk

Therapies Considered Ineffective — Denial Risk

The following therapies are considered ineffective for treatment of recurrent pregnancy loss and are not medically necessary; requests for these therapies risk denial.

Injection of paternal leukocytes (paternal white cell immunization or paternal cell alloimmunization).
Intravenous immunoglobulin (IVIG) therapy.

Clinical background

Recurrent pregnancy loss (RPL), also called recurrent spontaneous abortion, is variably defined in clinical practice and guidelines — commonly described as either two or more failed clinical pregnancies documented by ultrasound or histopathology, or three or more consecutive pregnancy losses. Etiologies are heterogeneous and may include genetic abnormalities, antiphospholipid syndrome, uterine structural anomalies, thrombophilias, hormonal or metabolic disorders, infection, autoimmune conditions, sperm quality issues, and environmental factors. Immunotherapies such as paternal leukocyte injection and IVIG have been proposed for putative alloimmune causes, but evidence and professional guidance do not demonstrate consistent benefit, and these therapies are therefore considered ineffective or not medically necessary for RPL.

Key definitions

Recurrent pregnancy loss (RPL) — definition

DefinitionRecurrent pregnancy loss (RPL) — spontaneous loss of 3 or more consecutive pregnancies or 2 or more failed clinical pregnancies documented by ultrasonography or histopathologic examination (definitions vary by guideline).

Alternative namesAlso referred to as recurrent spontaneous abortion or repeated miscarriage.

Common diagnostic thresholds3 or more consecutive pregnancy losses OR 2 or more failed clinical pregnancies confirmed by ultrasound or histopathology.

Note on guideline variabilityDefinition varies between national and international societies; some do not require losses to be intrauterine.

Suspected causes (non-exhaustive)Genetic factors, antiphospholipid syndrome, uterine anomalies, thrombophilias, hormonal/metabolic disorders, infection, autoimmunity, sperm quality, environmental/occupational/personal habit factors.