CurrentUnitedHealthcarePolicy N/A

Human chorionic gonadotropin (hCG) products prior authorization

Defines UnitedHealthcare prior authorization and coverage criteria for Novarel, Ovidrel, and Pregnyl (hCG products) for fertility and related indications, affecting providers requesting these medications for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyHuman chorionic gonadotropin (hCG) products prior authorization

Policy CodePolicy N/A

Change TypeAdded fertility preservation criteriaterminology clarified

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of diagnosis and required pretreatment (e.g., gonadotropin, clomiphene, letrozole) when requesting Novarel, Ovidrel, or Pregnyl.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for fertility preservation for iatrogenic infertility.

Updated terminology from 'controlled ovarian hyperstimulation' to 'ovarian stimulation'.

3medications

2 moovulation induction auth

12 mohypogonadotropic auth

6 wkcryptorchidism auth

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Coverage Criteria for hCG Products

Ovulation Induction

Approved when ALL of the following are met:

Ovulation induction: Diagnosis of anovulatory infertility

Ovulation induction: Infertility is not due to primary ovarian failure

Ovulation induction: For induction of ovulation

Authorization issued for 2 months

Ovulation induction: Patient has been pre-treated with a follicular stimulating agent (e.g., gonadotropin, clomiphene citrate, letrozole)

Ovarian Stimulation / Fertility Preservation

Approved based on ONE of the following sets:

Ovarian stimulation option A: All of the following: (1) Diagnosis of infertility; (2) For the development of multiple ovarian follicles; (3) Patient has been or will be pre-treated with a follicular stimulating agent (e.g., gonadotropin, clomiphene citrate, letrozole)

Authorization issued for 2 months

Ovarian stimulation option B (fertility preservation): All of the following: (1) Used for fertility preservation; (2) The individual will undergo gonadotoxic therapy (e.g., exposure to cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, radiation therapy); (3) Will be used as part of an assisted reproductive technology (e.g., in vitro fertilization)

Authorization issued for 2 months

Prepubertal Cryptorchidism

Approved when the following criterion is met:

Prepubertal cryptorchidism: Diagnosis of prepubertal cryptorchidism not due to anatomical obstruction

Authorization issued for 6 weeks

Hypogonadotropic Hypogonadism - Initial Authorization

Initial approval requires ALL of the following:

Diagnosis of hypogonadism secondary to pituitary deficiency

Low testosterone (below normal reference level provided by the physician's laboratory)

Gonadotropin deficiency evidence: One of the following: (a) Low LH (below normal reference level provided by the physician's laboratory) OR (b) Low FSH (below normal reference level provided by the physician's laboratory)

Authorization issued for 12 months

Hypogonadotropic Hypogonadism - Reauthorization

Reauthorization requires:

Clinical response: Documentation of positive clinical response to therapy

Authorization issued for 12 months

UnitedHealthcare excludes generic human chorionic gonadotropin (hCG), Novarel, and Ovidrel from coverage for the majority of benefit plans. This exclusion is stated in the policy's additional clinical rules and reference history and may affect initial approvals, reauthorizations, and automated approvals where applicable.

Because coverage for these products can vary by plan, providers should confirm the member's specific benefits before submitting a prior authorization request. State mandates or plan-specific provisions may override the general exclusion for some members.

Infertility-related indications are typically excluded from UnitedHealthcare coverage. Determinations for infertility treatments or medications (including hCG products) depend on the member's benefit plan and any applicable state mandates.

Providers must review the member's evidence of coverage or plan documents to confirm whether infertility services or drugs are covered before submitting requests for authorization.

Coding and Definitions

inv-09: Infertility duration thresholds — timing thresholds for evaluation

Infertility duration — female partner <35Failure to achieve pregnancy after 12 months or more of regular unprotected intercourse

Infertility duration — female partner ≥35Failure to achieve pregnancy after 6 months or more of regular unprotected intercourse

General infertility definitionInability to achieve a successful pregnancy due to an individual's medical, sexual, or reproductive history

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Novarel, Ovidrel, and Pregnyl for the indications below. Approvals and durations are listed with each indication. Note: member-specific benefits and state/federal mandates may affect coverage; infertility is typically excluded — verify member plan.

Prior authorization required for Novarel, Ovidrel, Pregnyl
Supply limitations and automated approval processes may apply
Exclusions: generic hCG, Novarel and Ovidrel excluded for majority of benefits; infertility often excluded — verify member benefits

Prior Authorization

Ovulation Induction Prior Authorization

Novarel, Ovidrel, or Pregnyl will be approved for ovulation induction when all of the following are met: diagnosis of anovulatory infertility; infertility is not due to primary ovarian failure; for induction of ovulation; and patient has been pre-treated with a follicular stimulating agent (e.g., gonadotropin, clomiphene citrate, letrozole). Authorization will be issued for 2 months.

Background and Clinical Context

Human chorionic gonadotropin (hCG) is a placentally produced hormone with structural and functional similarity to luteinizing hormone (LH). In clinical practice hCG is used to trigger ovulation during infertility treatment and for ovarian stimulation as part of assisted reproductive technologies.

Other clinical uses include induction of testicular descent for prepubertal cryptorchidism, initiating puberty or treating androgen deficiency in select hypogonadal conditions, and initiating or maintaining spermatogenesis in men with hypogonadotropic hypogonadism. Infertility is defined by duration thresholds that vary by age and may affect coverage determinations.

Defined Terms

inv-20: hCG definition — human chorionic gonadotropin description and sourcing

hCG descriptionHuman chorionic gonadotropin produced by the placenta and extracted from urine, chemically and functionally similar to luteinizing hormone (LH)

Primary clinical use — ovulationRoutinely used to trigger ovulation in the treatment of infertility

Use in cryptorchidismUsed to induce testicular descent in boys and to help predict need for orchiopexy; response may be temporary

Use in hypogonadal menUsed to induce puberty, treat androgen deficiency in hypogonadotropic hypogonadism, and initiate/maintain spermatogenesis in men desiring fertility

Policy Revision History

2026-06-01terminology_updateLatest

Updated terminology from 'controlled ovarian hyperstimulation' to 'ovarian stimulation' in coverage criteria headings and narrative.

2025-06-01material_addition

Expanded coverage criteria for fertility preservation to include additional examples of gonadotoxic therapy such as prolonged hormonal ovarian suppression.

2024-05-01material_addition