CurrentUnitedHealthcarePolicy 2026T0270MM

Infertility Diagnosis, Treatment, and Fertility Preservation

Medical policy governing UnitedHealthcare Commercial and most Individual Exchange benefit plans for diagnosis, treatment, and fertility preservation services related to infertility, including medically necessary and not medically necessary procedures and associated coding guidance.

Policy Summary

PayerUnitedHealthcare

PolicyInfertility Diagnosis, Treatment, and Fertility Preservation

Policy CodePolicy 2026T0270MM

Change TypeTemplate update / shared policy application

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization when the member's plan includes infertility benefits for ART, cryopreservation, or advanced fertility testing and provide clinical documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and archived previous policy versions 2025T0270LL and INFERTILITY 008.21.

~100+listed procedure and laboratory codes in Applicable Codes section

multipletests/procedures designated as proven and medically necessary

multipletests/procedures designated unproven and not medically necessary

Z31.84 requireddiagnosis code needed for fertility preservation for iatrogenic infertility

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.

one cyclelimit for fertility preservation per covered person

Oxford plannew shared policy application

Coverage Criteria and Evidence Summary

Uterine receptivity testing and endometrial interventions

There is insufficient evidence supporting the safety and efficacy of uterine receptivity testing and endometrial interventions. The following summarizes evidence and provides coverage guidance.

ALL of the following

Uterine/endometrial receptivity testing (e.g., ERA or other proprietary endometrial gene-expression assays) is considered unproven and not medically necessary for routine use in infertility evaluation or treatment.
Endometrial interventions intended to improve receptivity (e.g., endometrial scratching/injury, immunotherapy, uterine artery vasodilation) are considered unproven and not medically necessary outside of clinical trials.
- ALL of the following
  - The member has documented repeated implantation failure (RIF) defined by the treating clinician and supported by medical records;
  - The treating reproductive specialist documents the rationale for testing or intervention, including prior standard evaluations and treatments tried;
  - Results of testing or proposed intervention would directly change management and there is clear documentation of how the results would be used to alter embryo transfer timing or other therapy;
  - The member-specific benefit plan allows coverage for such testing or interventions;

Applicable Codes and Coding Notes

Applicable procedure, lab, and supply codesmixed

0253U	Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes
0255U	Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns
52402	Cystourethroscopy with transurethral resection or incision of ejaculatory ducts
54500	Biopsy of testis, needle (separate procedure)
54505	Biopsy of testis, incisional (separate procedure)
55300	Vasotomy for vasograms, seminal vesiculograms, or epididymograms
55530	Excision of varicocele or ligation of spermatic veins; (separate procedure)
55535	Excision of varicocele or ligation of spermatic veins; abdominal approach
55550	Laparoscopy, surgical, with ligation of spermatic veins for varicocele
55870	Electroejaculation

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Applicable CPT codesCPT

89300	Semen analysis; presence and/or motility of sperm including Huhner test (post coital).
89310	Semen analysis; motility and count (not including Huhner test).
89320	Semen analysis; volume, count, motility, and differential.
89321	Semen analysis; sperm presence and motility of sperm, if performed.
89322	Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger).
89325	Sperm antibodies.
89329	Sperm evaluation; hamster penetration test.
89330	Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test.
89331	Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated).
89335	Cryopreservation, reproductive tissue, testicular.

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Applicable HCPCS/S codes and J-codesHCPCS

J0725	Injection, chorionic gonadotropin, per 1,000 USP units.
J3355	Injection, urofollitropin, 75 IU.
S0122	Injection, menotropins, 75 IU.
S0126	Injection, follitropin alfa, 75 IU.
S0128	Injection, follitropin beta, 75 IU.
S0132	Injection, ganirelix acetate, 250 mcg.
S3655	Antisperm antibodies test (immunobead).
S4011	In vitro fertilization; including identification and incubation of mature oocytes, fertilization, embryo incubation, and visualization for development.
S4013	Complete cycle, gamete intrafallopian transfer (GIFT), case rate.
S4014	Complete cycle, zygote intrafallopian transfer (ZIFT), case rate.

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Applicable ICD-10 diagnosis codesICD-10

E23.0	Hypopituitarism.
N46.01	Organic azoospermia.
N46.021	Azoospermia due to drug therapy.
N46.022	Azoospermia due to infection.
N46.023	Azoospermia due to obstruction of efferent ducts.
N46.024	Azoospermia due to radiation.
N46.025	Azoospermia due to systemic disease.
N46.029	Azoospermia due to other extratesticular causes.
N46.11	Organic oligospermia.
N46.121	Oligospermia due to drug therapy.

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Codes referenced in evidence excerpt (supporting code references)mixed

No codes listed

Time to diagnose infertility — policy thresholds

Policy definition of infertility timingFailure to achieve pregnancy after 12 months of regular unprotected intercourse when the female partner is <35, or after 6 months when the female partner is ≥35.

Clinical contextIncludes inability to achieve a successful pregnancy due to an individual's medical, sexual, or reproductive history.

Use for benefit eligibilityMember must meet the policy timing criteria (12 months or 6 months as above) and have infertility not related to voluntary sterilization or failed reversal to be eligible for infertility services.

CASA reliability and recommendation

CASA test performance summaryComputer-assisted sperm analysis (CASA) studies demonstrate low specificity, low sensitivity, and a high rate of false positives, with increased variability at low (<15 million/mL) and high (>60 million/mL) sperm concentrations.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Plan applicability and prior authorization context

This policy applies to UnitedHealthcare Commercial and Individual Exchange plans where the member-specific benefit includes infertility or fertility preservation benefits. Prior authorization may be required for certain ART services, cryopreservation, and related procedures — verify member benefits and obtain prior authorization when the plan requires it.

Applies to UnitedHealthcare Commercial and Individual Exchange plans (see member specific benefit document).
Prior authorization context: member-specific benefit governs; obtain prior auth when required by the plan.

Denial Risk

Coverage limits and common denial triggers

Benefits for infertility and fertility preservation are member-specific. Coverage is limited to services and maximums in the member’s plan; when the plan excludes infertility benefits, services including ART, storage, and retrieval are not covered. Long-term storage beyond the plan allowance (greater than one year) is not covered. Absence of required documentation or evidence of benefits may trigger denial.

Background and Definitions

Background: For this policy, infertility is defined as the inability to achieve pregnancy due to medical, sexual, or reproductive history, or failure to conceive after specified durations of unprotected sexual intercourse (12 months when the female partner is under 35 years or 6 months when the female partner is ≥35 years). The policy applies this clinical context when determining the appropriateness of diagnostic testing and treatment options for infertility [[chunk 9]][[chunk 7]].

Iatrogenic infertility — definition and context

DefinitionIatrogenic infertility: impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

Common causes citedExamples include planned chemotherapy, radiation treatment, and bilateral oophorectomy leading to irreversible infertility risk.

Relation to fertility preservation benefitsCertain plans may include coverage for fertility preservation when iatrogenic infertility risk is documented per the member-specific benefit plan.

Infertility — definition used in this policy

Policy Revision History

Policy Summary

PayerUnitedHealthcare

PolicyInfertility Diagnosis, Treatment, and Fertility Preservation

Policy CodePolicy 2026T0270MM

Change TypeTemplate update / shared policy application

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

Manual semen analysis recommendationManual semen analysis remains the gold standard when performed by highly trained technologists in accredited laboratories and monitored by external agencies.

Current validity of CASACASA may be a valid alternative for evaluating sperm concentration and motility but requires further technological improvements before replacing manual analysis for all parameters (morphology especially unreliable).

FSH recovery threshold and graft outcomes

FSH recovery thresholdMedian time to return of FSH to <25 IU/L after ovarian tissue transplantation was 19 weeks.

Endocrine outcome changePooled mean pre-transplant FSH decreased from 66.4 IU/L pre-transplant to 14.1 IU/L post-transplant in the meta-analysis.

Graft function durationMedian duration of graft function after ovarian tissue transplantation was approximately 2.5 years.

Hyaluronic acid concentrations compared in transfer media studies

HA concentrations compared in trialsStudies compared low/standard HA concentration of 0.125 mg/mL versus enriched HA concentration of 0.5 mg/mL in embryo transfer media.

Effect in autologous cyclesHA-enriched media increased live birth and clinical pregnancy rates in autologous oocyte cycles in pooled analyses.

Effect in donor cyclesHA addition showed little effect on live birth and clinical pregnancy in donor oocyte cycles; evidence limited for donor cycles.

Triggers for denial include: plan excludes infertility benefits; requested services exceed benefit maximums; long-term storage beyond allowed duration; services for elective fertility preservation; services related to voluntary sterilization or failed reversal.
When plan does not include infertility benefits, all infertility treatments, IVF, and storage/retrieval of reproductive materials are not covered.

Documentation Required

Required documentation and medical necessity support

Documentation to support medical necessity must be provided and may be requested during review. Medical records are required to establish the diagnosis, that infertility is not due to voluntary sterilization or failed reversal, and to justify fertility preservation when due to iatrogenic (gonadotoxic) exposures. Missing or incomplete records may result in denial.

Required documentation examples: complete infertility evaluation results (history, semen analysis, prior treatments), evidence that infertility is not due to voluntary sterilization, and plan-specific benefit confirmation.
For fertility preservation due to iatrogenic infertility, document diagnosis (e.g., cancer), planned gonadotoxic treatment, indication for ovarian tissue cryopreservation/egg/embryo cryopreservation, and that the procedure is not elective.

Documentation Required

Ovarian tissue cryopreservation/transplant documentation

Ovarian tissue cryopreservation and transplantation may be considered when medically indicated (e.g., gonadotoxic treatment) but requires detailed documentation: diagnosis, prior or planned gonadotoxic exposure, prior fertility preservation options considered, and clinical rationale. Evidence is limited and reviewers may request records to establish necessity and expected benefit.

Include diagnosis and treatment plan (e.g., chemotherapy, radiation, bilateral oophorectomy).
Document rationale for ovarian tissue cryopreservation versus standard options and any contraindications to standard oocyte/embryo cryopreservation.

Prior Authorization

HA-enriched embryo transfer media may require justification

HA-enriched embryo transfer media (e.g., EmbryoGlue) has evidence of modest improvement in clinical pregnancy and live birth in some settings but variable results across studies. Use may require clinical justification tied to specific clinical indications and member benefit availability.

If billing or requesting coverage for HA-enriched media, document clinical reason and link to expected benefit (autologous oocyte cycles or single embryo transfer strategies).
Member-specific benefit and plan terms determine coverage; provide prior authorization when required.

Denial Risk

Advanced diagnostic/testing denial risk and documentation expectations

Advanced sperm functional tests (HBA, PICSI, Cap-Score), sperm DNA fragmentation testing, sperm penetration assays, and some uterine receptivity testing modalities have insufficient evidence of routine clinical utility. Requests for these tests or treatments should include prior diagnostic workup and justification; expect potential denial when used routinely without indication.

Advanced sperm tests (HBA, PICSI, Cap-Score) — insufficient evidence; may be denied without clear indication or trial of standard evaluation.
Sperm DNA fragmentation — potential denial risk: not recommended as part of initial evaluation and clinical utility to guide management is unproven.
Sperm Penetration Assay (SPA) — limited utility and standardization; may be denied.
Uterine receptivity testing/treatment (ERA, pET, endometrial scratch) — insufficient evidence for routine use; individual justification required, and some indications (e.g., RIF of endometrial origin) may be considered with documentation.

Step Therapy

Stepwise evaluation before advanced testing

Follow guideline-recommended stepwise evaluation before ordering advanced tests or treatments. For male infertility, begin with reproductive history and semen analysis; if abnormal, proceed with complete history, physical exam, and hormonal testing. Sperm DNA fragmentation and other advanced tests are not recommended in the initial evaluation without prior workup.

Stepwise approach: initial evaluation (history, semen analysis) → abnormal findings → complete evaluation (history, physical, hormonal testing) → consider advanced tests only after initial workup and when results will change management.
Document prior steps and why advanced testing is necessary to support medical necessity and prior authorization requests.

Step Therapy

Step‑up from IVM to standard IVF — evidence and justification

In vitro maturation (IVM) may be inferior to standard IVF in some populations (e.g., PCOS). When proposing IVM as a step-up or alternative to standard IVF, include clinical justification and supporting evidence; expect payor review and potential denial when evidence of superiority or equivalence is lacking.

Note from trials: one RCT in PCOS showed lower cumulative ongoing pregnancy with IVM versus standard IVF; include rationale if IVM is requested instead of standard IVF.
If IVM is proposed after failed standard approaches, document prior IVF attempts and rationale for IVM trial.

Note

Check member-specific plan and mandates

Always check the member-specific benefit plan and applicable federal/state mandates before applying this policy. The member’s plan document governs in the event of any conflict. UnitedHealthcare may use tools (e.g., InterQual) to assist in benefit administration.

Verify coverage, benefit maximums, exclusions, and prior authorization requirements in the member-specific plan.
Confirm whether fertility preservation or infertility benefits are included for the member and whether state/federal mandates apply.

Policy definition of infertilityInfertility: inability to achieve a successful pregnancy due to medical, sexual, or reproductive history; failure to achieve pregnancy after specified durations (12 months if female partner <35; 6 months if ≥35).

Eligibility noteTo be eligible for infertility benefits, the member must have infertility not related to voluntary sterilization or failed reversal.

Guideline alignmentDefinition aligns with professional society definitions cited (ASRM, ACOG, CDC, WHO) as noted in policy background.

Preimplantation Genetic Testing (PGT) — definition

PGT overviewPreimplantation Genetic Testing (PGT) analyzes DNA from oocytes or embryos for HLA-typing or genetic abnormalities, including PGT-A (aneuploidy), PGT-M (monogenic), and PGT-SR (structural rearrangements).

Clinical usePGT is performed on oocytes or embryos to detect numeric or structural chromosomal abnormalities or single-gene defects prior to transfer.

Nomenclature notePolicy references updated terminology (PGT-A, PGT-M, PGT-SR) corresponding to former terms (PGS, PGD).

Therapeutic Donor Insemination (TDI) — definition

TDI definitionTherapeutic Donor Insemination (TDI): insemination using a donor sperm sample for the purpose of conceiving a child; donor may be anonymous or directed.

Benefit contextTDI is included among insemination procedures (AI/IUI) covered when the member's plan provides infertility benefits and medical necessity criteria are met.

TerminologyPolicy uses 'Therapeutic Donor Insemination' interchangeably with donor sperm insemination for conception purposes.

Cryopreservation — definition

Cryopreservation definitionCryopreservation: the process of cooling and storing cells, tissues, or organs at very low or freezing temperatures to preserve sperm, oocytes (eggs), embryos, ovarian tissue, or testicular tissue for future use.

Common indicationsUsed for fertility preservation prior to therapies that threaten reproductive health (e.g., cancer treatment) and to store gametes or embryos from ART for later use.

Methods includedIncludes sperm cryopreservation, oocyte cryopreservation, embryo cryopreservation, and cryopreservation of reproductive tissues when applicable and per benefit coverage.

Therapeutic Donor Insemination — alternate definition

Therapeutic Donor Insemination (alternate wording)Use of donor sperm sample for the purpose of conceiving a child; included under insemination procedures when provided under physician supervision and when member benefits allow.

Coverage limit contextTDI coverage and applicability depend on the member-specific benefit plan and medical necessity criteria.

Donor typesDonor may be anonymous or directed per policy definition and clinical practice.

Fertility preservation for iatrogenic infertility — definition

Fertility preservation for iatrogenic infertility — definitionProcedures provided because medical treatment is expected to cause irreversible infertility (e.g., collection and cryopreservation of sperm, oocytes, or embryos; ovarian stimulation/retrieval).

Covered examplesServices can include sperm collection and cryopreservation, oocyte retrieval and cryopreservation, and embryo cryopreservation when the member's plan includes fertility preservation benefits.

Benefit determinationCoverage depends on the member-specific benefit plan; documentation of the planned gonadotoxic treatment or surgical procedure is required to support medical necessity.

Ovarian tissue cryopreservation and transplantation — definition and outcomes

Ovarian tissue cryopreservation/transplantation — definitionHarvesting ovarian tissue for freezing and later re-implantation to restore endocrine function and fertility.

Outcomes summarizedSystematic review pooled pregnancy rates: frozen transplants 37% (pregnancy) and 28% (live birth); fresh transplants 52% (pregnancy) and 45% (live birth); median graft function ~2.5 years.

Evidence limitationsEvidence limited by small, heterogeneous studies; larger well-characterized studies needed to define optimal techniques and expected outcomes.

EmbryoGlue / HA-enriched transfer media — definition

EmbryoGlue / HA-enriched media definitionEmbryo transfer culture medium supplemented with higher concentrations of hyaluronic acid (HA) intended to improve embryo adhesion and implantation.

Typical concentrations comparedTrials compared standard/low HA (0.125 mg/mL) versus enriched HA (0.5 mg/mL) in transfer media.

Observed effectsMeta-analyses report probable increases in clinical pregnancy and live birth in autologous cycles but little effect in donor cycles; HA may also increase multiple pregnancy rates if multiple embryos transferred.

Sperm DNA fragmentation (SDF) testing — definition and context

SDF testing definitionSperm DNA fragmentation (SDF) tests are laboratory assays that measure DNA strand breaks in sperm and have been associated in studies with reduced fertilization, embryo quality, implantation, and live birth rates in ART.

Evidence and limitationsSystematic reviews and meta-analyses show inconsistent associations with ART outcomes; prospective studies demonstrating impact on management are lacking.

Policy stanceThere is insufficient evidence to support routine use of SDF testing to guide infertility management; testing is considered investigational/adjunctive pending further data.

Cap-Score — definition and evidence

Cap-Score definitionCap-Score assesses sperm capacitation via localization patterns of the ganglioside GM1 and is proposed as a complementary measure to standard semen analysis to predict male fertility.

Key study findingsIn one small study, a Cap-Score threshold ≥39.5% identified patients with a high rate (92.3%) of subsequent clinical pregnancy (natural conception or ≤3 IUI cycles) among 42 patients.

Policy interpretationEvidence is preliminary with small sample sizes; Cap-Score is not established for routine clinical use to direct management.

Sperm DNA Fragmentation (SDF/DFI) — definition and context

SDF/DFI termSperm DNA Fragmentation (SDF/DFI) refers to laboratory measures of DNA strand breaks in sperm (e.g., SCSA, TUNEL, Comet, SCD) proposed to correlate with ART outcomes.

Meta-analysis findingsRecent meta-analyses report mixed results: some cohort studies suggest adverse associations with fertilization and pregnancy outcomes while other pooled analyses show no significant association with IVF/ICSI outcomes.

Clinical utilityProspective trials demonstrating that SDF testing changes management and improves outcomes are lacking; routine use is not supported by current evidence.

Endometrial Receptivity Analysis (ERA) — definition

ERA definitionEndometrial Receptivity Analysis (ERA) is a molecular assay intended to identify the window of implantation to guide personalized embryo transfer timing.

Evidence summaryMeta-analyses and RCTs show mixed results: no consistent improvement in live birth or ongoing pregnancy across general IVF populations, though some data suggest potential benefit in selected subgroups (e.g., non-receptive ERA in RIF).

Incidence of displaced WOIEstimates of displaced window of implantation by ERA are approximately 34–38% in some series for good-prognosis and RIF patients.

Endometrial scratching — definition and trial context

Endometrial scratching definitionEndometrial scratching (intentional endometrial injury) is performed prior to embryo transfer and has been proposed to improve implantation.

Trial context and outcomesRCTs and meta-analyses report mixed results: some earlier trials/meta-analyses showed modest benefit when performed between day 7 of the preceding cycle and day 7 of transfer, while large RCTs (e.g., Lensen et al. 2019, SCRaTCH) found no clear benefit; SCRaTCH recommended limiting use to clinical trials.

Policy recommendationEndometrial scratching should not be performed routinely outside clinical trials and, if used, should be supported by clear documentation of indication.

References supporting the policy

Key bibliographic sourcesPolicy references systematic reviews, RCTs, and society guidelines including Cochrane reviews and recent meta-analyses (e.g., Heymann 2020/2022; Khattak 2022; Cardona 2017; Chen 2022; Liu 2022; Lensen 2019; Zheng 2022).

Scope of evidence citedCited literature covers embryo transfer media (HA), ovarian tissue cryopreservation/transplantation, CASA, Cap-Score, SDF/DFI meta-analyses, ERA, endometrial scratching, and IVM trials.

Use in policy rationaleThese references support the policy's determinations of proven, unproven, and investigational services and guide benefit/authorization recommendations.