Loading...

UnitedHealthcare hCG Prior Auth Coverage Update | OpenPayer

CurrentUnitedHealthcarePolicy N/A

UnitedHealthcare Clinical Policy: Human chorionic gonadotropin (hCG) therapies (Novarel, Ovidrel, Pregnyl) - Prior Authorization and Coverage Criteria

Defines UnitedHealthcare prior authorization and coverage criteria for Novarel, Ovidrel, and Pregnyl for infertility-related uses, prepubertal cryptorchidism, and hypogonadotropic hypogonadism; applies to benefit plans administered by UnitedHealthcare and providers seeking prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyClinical/Medical Policy — Reproductive Health & Fertility (coverage criteria for Novarel, Ovidrel, Pregnyl)

Policy CodePolicy N/A

Change TypeMaterial additions and terminology revision

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document required pretreatment or laboratory criteria per indication (authorization periods vary by indication).

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for fertility preservation for iatrogenic infertility (examples of gonadotoxic therapy expanded to include prolonged hormonal ovarian suppression).

Updated term 'controlled ovarian hyperstimulation' to 'ovarian stimulation' in coverage criteria.

3medications governed by this program

2 moovulation/ovarian stimulation auth

12 mohypogonadotropic hypogonadism auth

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.

Coverage Criteria

Ovulation Induction

Approved when ALL of the following are met:

Ovulation Induction criteria: a. Diagnosis of anovulatory infertility

Authorization issued for 2 months

Ovulation Induction criteria: b. Infertility is not due to primary ovarian failure

Authorization issued for 2 months

Ovulation Induction criteria: c. For induction of ovulation

Authorization issued for 2 months

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

Authorization issued for 2 months

Ovarian Stimulation / Fertility Preservation

Approved when ONE of the following sets is satisfied:

Ovarian stimulation pathway A: All of: (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 pathway B - fertility preservation: All of: (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) procedure

Authorization issued for 2 months

Prepubertal Cryptorchidism

Approved when the following is met:

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

Authorization issued for 6 weeks

Hypogonadotropic Hypogonadism

Initial authorization requires ALL of the following; reauthorization requires documentation of response:

Initial hypogonadotropic hypogonadism criteria: (1) Diagnosis of hypogonadism secondary to pituitary deficiency; (2) Low testosterone (below normal reference level provided by the physician's laboratory); (3) One of: low LH or low FSH (below normal reference level provided by the physician's laboratory)

Initial authorization issued for 12 months

Reauthorization hypogonadotropic hypogonadism: Documentation of positive clinical response to therapy

Reauthorization issued for 12 months

Human chorionic gonadotropin products (Novarel, Ovidrel, and Pregnyl) are governed by specific prior authorization criteria for select reproductive and endocrine indications. However, human chorionic gonadotropin (generic), Novarel and Ovidrel are excluded from coverage for the majority of benefits. Coverage for infertility-related use may be limited or excluded depending on the member’s benefit plan; authorization may still be issued in accordance with the policy’s specified clinical criteria when the member’s benefit allows.

Infertility services are typically excluded from UnitedHealthcare coverage. Whether an infertility indication for hCG therapy is covered depends on the member’s specific benefit plan; providers should verify plan benefits before submitting a request for prior authorization.

Coding

No explicit codes providedmixed

Note: The document does not list specific CPT/HCPCS/ICD-10/NDC codes; it references exclusions and prior authorization program but provides no explicit billing codes.

inv-08: Low testosterone / LH / FSH — laboratory reference requirements

Laboratory thresholdsLow testosterone, LH, or FSH must be reported as below the normal reference range provided by the ordering physician’s laboratory.

Test documentationInitial authorization requires laboratory documentation of low testosterone and either low LH or low FSH as reported by the physician’s laboratory.

Reference sourceValues are interpreted relative to the physician’s laboratory reference ranges (no absolute numeric cutoffs specified in the policy).

Reauthorization requirementAuthorization for hypogonadotropic hypogonadism is issued for 12 months (laboratory confirmation required at initial review; reauthorization requires documentation of positive clinical response).

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Novarel, Ovidrel, and Pregnyl. Providers must request authorization before dispensing these products for covered indications.

Affected products: Novarel, Ovidrel, Pregnyl
Prior authorization required for initial and reauthorization requests

Prior Authorization

Pre-treatment Requirement

Pre-treatment with a follicle stimulating agent is required for ovulation induction and ovarian stimulation when using Novarel, Ovidrel, or Pregnyl. Examples of acceptable pre-treatment agents include gonadotropins, clomiphene citrate, or letrozole.

Required pre-treatment: gonadotropin, clomiphene citrate, or letrozole
Applies to: ovulation induction and development of multiple ovarian follicles

Definitions

inv-14: Infertility definition — timing thresholds for inability to achieve pregnancy by partner age

Definition (general)Infertility: inability to achieve a successful pregnancy due to an individual’s medical, sexual, or reproductive history.

Timing when female partner is <35 yearsFailure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.

Background

Human chorionic gonadotropin (hCG) is a gonadotropin that is biologically similar to luteinizing hormone and is used clinically to trigger ovulation and induce final follicular maturation in assisted reproductive procedures, to treat prepubertal cryptorchidism, and to induce puberty or support spermatogenesis and androgen production in hypogonadotropic hypogonadism.

Revision History

2025-09-01policy_effective_dateLatest

Policy effective date set to 9/1/2025.

2025-06-01criteria_revision

Updated coverage criteria for fertility preservation to include additional examples of gonadotoxic therapy (e.g., prolonged hormonal ovarian suppression) and clarified ovarian stimulation terminology; authorization issued for 2 months for ovarian stimulation/fertility preservation.

2024-05-01