ModifiedUnitedHealthcarePolicy BIP067.S

Family Planning: Infertility Services

Defines UnitedHealthcare West coverage for diagnosis, treatment, cryopreservation, donor/surrogate services, and fertility preservation for iatrogenic infertility for members in applicable California markets.

Policy Summary

PayerUnitedHealthcare

PolicyFamily Planning: Infertility Services

Policy CodePolicy BIP067.S

Change TypeModified — expanded covered benefits and fertility preservation rules

Effective DateJune 1, 2026

Next Review Date

Key ActionVerify member EOC/Schedule of Benefits for plan-specific infertility benefit applicability and prior authorization requirements before proceeding; obtain physician recommendation and member attestation when pursuing iatrogenic fertility preservation.

SourceLink

POLICY UPDATE CHANGES

Revised list of covered indications for California Large Groups, including diagnostic services, IVF, donor procurement, three attempts to collect or retrieve sperm, and three completed oocyte retrievals.

Revised fertility preservation eligibility to include (1) planned treatment within 12 months with physician recommendation and member attestation, or (2) prior treatment where the member was unable to undergo or complete preservation and continues to face risk of infertility.

Expanded fertility preservation services to add gonadal shielding or transposition, extended long-term storage rules (minimum 3 years, extended coverage up to age 26 for those who begin preservation before age 26), and other storage details.

Added instruction to refer to the member's Explanation of Coverage (EOC) and Schedule of Benefits for further information and applicability.

Revised list of covered indications and services for infertility, including diagnostic surgery, IVF, donor procurement, and limits on sperm collection and oocyte retrievals.

Revised cryopreservation storage duration: minimum 3 years with extended coverage up to age 26 for those who begin preservation before age 26.

Added coverage items including cryopreservation of fertilized embryos (except for non-iatrogenic preservation), donor eggs/sperm, host uterus services for fertility impairment due to elective sterilization, and oocyte preservation.

Added instruction to refer to member's Explanation of Coverage (EOC)/Schedule of Benefits for specific coverage, limitations, and exclusions.

For California Small Groups, added language that infertility services coverage is only available if purchased by the employer group as a supplemental benefit and that a supplement to the Combined Evidence of Coverage and Disclosure Form will be provided.

3completed oocyte retrievals covered

3sperm collection attempts covered

3 yrsminimum cryopreservation storage

age 26extended storage up to

Californiaapplicability

Coverage Criteria and Medical Necessity

Covered services and fertility preservation criteria

Covered when the plan includes infertility benefits or as required by California law for applicable groups; specific eligibility, limits, and applicability vary by group type.

California Large Group - Diagnosis of Infertility: Diagnosis includes but is not limited to diagnostic surgery and biopsy; physician services including consultation and referral; screening and diagnostic laboratory and imaging services; semen analysis.

Referenced in Covered Benefits section

California Large Group - Medically Necessary Treatment: Includes but is not limited to in vitro fertilization (IVF); procurement of donor semen, oocyte, and embryo; surgery to treat infertility; thawing of previously cryopreserved gametes, embryos, and tissues.

Expanded list per policy revision; numeric limits (see separate node)

Quantity limits for gamete retrieval/collection: Three attempts to collect or retrieve sperm and three completed oocyte retrievals are covered.3

Explicit numeric limits

Cryopreservation (Covered Benefits) - storage baseline: Cryopreservation and storage of sperm, oocytes, and embryos for a period of at least five years from the time the genetic material is first cryopreserved (as listed in Covered Benefits).at least 5 years (Covered Benefits)

See Covered Benefits list in policy history

Fertility Preservation for Iatrogenic Infertility - Eligibility: Benefits are available if EITHER: (1) the member's physician recommends the member will receive a covered medical treatment that may cause infertility, the physician recommends the member receive such treatment within the next 12 months, and the member attests they plan to undergo such treatment within 12 months; OR (2) the member already received a covered medical treatment that may cause infertility, was unable to undergo or complete fertility preservation cycles due to their medical condition, and faces an ongoing risk for infertility from that treatment.

Two alternative clinical scenarios

Fertility Preservation - Covered procedures when supervised by a physician: Collection of sperm; cryopreservation of sperm; ovarian stimulation, retrieval of eggs and fertilization; oocyte cryo-preservation; embryo cryo-preservation; gonadal shielding or transposition during a procedure or treatment (if not already included in usual coverage); benefits for related medications as described under outpatient prescription drug supplement or pharmaceutical products; long-term storage costs related to iatrogenic infertility.

Services listed in Fertility Preservation section

Cryopreservation storage duration for iatrogenic infertility: Storage of sperm, oocytes, gonadal tissue, and embryos: all eligible individuals receive a minimum of 3 years of storage from time of first preservation; extended coverage up to age 26 for those who begin preservation before age 26.minimum 3 years; extension to age 26

Replaces prior one-year storage language

Covered when medically necessary

Covered infertility and fertility preservation services when medically necessary and when benefits are included in the member's plan:

Covered indications/services: Includes diagnostic surgery and biopsy; physician services including consultation and referral; screening and diagnostic laboratory and imaging services; semen analysis; medically necessary treatment of infertility including in vitro fertilization (IVF); procurement of donor semen, oocyte, and embryo; surgery to treat infertility; thawing of previously cryopreserved gametes, embryos, and tissues; donor and surrogate services including gamete and embryo transfer, genetic testing and screening, laboratory and imaging services; cryopreservation and storage of sperm, oocytes, and embryos for at least five years from the time first cryopreserved (as part of Covered Benefits list).

From revised Covered Benefits list

Quantity limits: Three attempts to collect or retrieve sperm and three completed oocyte retrievals are covered.3

Explicit numeric limits specified in policy history

Fertility preservation for iatrogenic infertility:

Reversal of sterilization procedures are not covered under this policy and would be denied.

Cryopreservation of fertilized embryos is included in the policy only when provided as part of iatrogenic fertility preservation; non‑iatrogenic embryo cryopreservation is not listed as a covered benefit in this section.

There are no additional explicit statements in this section designating other services as not medically necessary beyond those specifically listed.

Coverage is subject to the member's specific plan provisions; services not included in the member's Evidence of Coverage/Schedule of Benefits are not considered covered. Refer to the member's EOC/SOB for applicable limits, exclusions, and any plan‑level requirements.

Coding and Definitions

No codes listedmixed

No codes listed

Time to establish infertility — age-based thresholds for duration

Time thresholds to establish infertilityFailure to establish pregnancy after regular, unprotected intercourse: ≤12 months for persons under 35 years; ≤6 months for persons 35 years or older.

Physician findings may establish infertility earlierA licensed physician's findings based on medical, sexual, and reproductive history, age, physical findings, or diagnostic testing can establish infertility before the time thresholds are met.

Definition sourcePer California Health and Safety Code Section 1374.55 — used to operationalize plan criteria for California markets.

Plan applicability noteThese time thresholds are referenced when determining eligibility for covered infertility services for applicable California groups as described in the policy.

Provider Actions, Verification & Prior Authorization

Prior Authorization

Benefit verification required

Verify member plan-level benefits, including whether infertility services or an infertility supplemental benefit was purchased by the employer group. For California small groups, infertility services are only available if purchased as a supplemental benefit — refer to the member's Schedule of Benefits and any supplement to the Combined Evidence of Coverage and Disclosure Form.

Check Schedule of Benefits (SOB) and Evidence of Coverage (EOC) for applicable coverage and limits
California small group rule: infertility services covered only if purchased as supplemental benefit
If supplemental benefit applies, member will receive a supplement to the Combined EOC/Disclosure Form

Prior Authorization

Refer to EOC/SOB for prior authorization

Definitions and Background

Infertility is defined (per applicable California statute) as a condition demonstrated by physician findings, an inability to reproduce without medical intervention, or failure to establish pregnancy after regular unprotected intercourse — generally ≤12 months if under age 35 or ≤6 months if age 35 or older.

Infertility definition — physician findings and time thresholds

Clinical definition of infertilityA condition characterized by physician findings, inability to reproduce without medical intervention, or failure to establish pregnancy after regular, unprotected intercourse.

Time-based criteriaFailure to establish pregnancy after regular, unprotected intercourse: ≤12 months if under 35 years; ≤6 months if 35 years or older.

Physician findings allowanceA licensed physician's findings (based on history, age, physical findings, diagnostic testing, or combination) can define infertility and do not prevent testing before the 12‑ or 6‑month period.

Iatrogenic infertility — caused by surgery, chemotherapy, radiation, or other medical treatment

Policy Summary

PayerUnitedHealthcare

PolicyFamily Planning: Infertility Services

Policy CodePolicy BIP067.S

Change TypeModified — expanded covered benefits and fertility preservation rules

Effective DateJune 1, 2026

Next Review Date

SourceLink

On This Page

Covered when EITHER: (1) the member's physician has recommended a covered medical treatment that may cause infertility, the physician recommends the member receive such treatment within the next 12 months, and the member attests they plan to undergo such treatment within 12 months; OR (2) the member already received a covered medical treatment that may cause infertility, was unable to undergo or complete preservation, and faces ongoing risk for infertility due to reproductive damage from that treatment.

Two alternative clinical scenarios from Fertility Preservation section

Cryopreservation storage duration for iatrogenic infertility: Storage of sperm, oocytes, gonadal tissue, and embryos: minimum of 3 years from time of first preservation; extended coverage up to age 26 for those who begin preservation before age 26.minimum 3 years; extension to age 26

Replaces prior one-year storage language

Prior authorization requirements vary by plan. Refer to the member's Evidence of Coverage (EOC) and Schedule of Benefits (SOB) for plan-specific prior authorization expectations and any required authorization processes before scheduling services.

Follow plan EOC/SOB for prior authorization rules and contact the payer for plan-specific instructions

Documentation Required

Physician recommendation and member attestation required

Providers must document the physician recommendation and member attestation to establish eligibility for fertility preservation for iatrogenic infertility. The physician must state that the member is to receive (or has received) a covered medical treatment that may cause infertility and the timing of that treatment. The member must attest they plan to undergo the treatment within 12 months when applicable, or document inability to complete prior preservation with ongoing risk.

Physician recommendation must indicate treatment that may cause infertility and timing (within next 12 months if applicable)
Member attestation that they plan to undergo the recommended treatment within 12 months, or documentation that prior preservation could not be completed and ongoing infertility risk exists
Retain documentation in the medical record to support medical necessity for fertility preservation procedures

Denial Risk

Not covered procedures

Reversal of sterilization procedures are not covered. Verify coverage for services related to infertility and do not bill reversal of sterilization as a covered benefit.

Reversal of sterilization procedures — Not covered

Note

EOC/SOB governs coverage discrepancies

When the policy and the member's EOC/SOB differ, the member's EOC/SOB governs. Use the member's EOC/SOB to make final coverage determinations and resolve discrepancies.

EOC/SOB governs coverage discrepancies — rely on member-specific documents for final determination

Iatrogenic infertility definitionInfertility caused directly or indirectly by surgery, chemotherapy, radiation, or other medical treatment.

Regulatory referenceDefined under California HSC Section 1374.551 as infertility resulting from medical treatments that may cause reproductive harm.

Guideline linkageTreatment types that 'may directly or indirectly cause' iatrogenic infertility are established by ASCO or ASRM guidance (per statute).

Iatrogenic infertility detail — coverage for fertility preservation when at-risk treatments or prior inability to preserve applies

Coverage eligibility — planned at‑risk treatmentCovered when the member's physician recommends a covered medical treatment that may cause infertility, the physician recommends the member receive such treatment within the next 12 months, and the member attests they plan to undergo the treatment within 12 months.

Coverage eligibility — prior inability to preserveCovered when the member previously received a covered treatment that may cause infertility, was unable to undergo or complete fertility preservation, and continues to face ongoing risk for infertility from that treatment.

Services includedStandard fertility preservation services and related procedures (e.g., gonadal shielding or transposition when not otherwise included) and cryopreservation of sperm, oocytes, gonadal tissue, and embryos are covered as described.

Storage duration rulesMinimum 3 years of storage from first preservation for all eligible individuals, with extended coverage up to age 26 for those who begin preservation before age 26.