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    v1.0.30
    OpenPayerPolicy UpdatesReproductive Health & FertilityUnitedHealthcare Menopur Prior Auth | OpenPayer
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    CurrentUnitedHealthcarePolicy N/A

    Menopur (menotropins) coverage for infertility treatment and fertility preservation

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    This policy governs prior authorization and notification requirements for Menopur (menotropins) used for ovarian stimulation, off-label ovulation induction, male hypogonadotropic hypogonadism, and fertility preservation. Coverage is subject to clinical criteria, authorization-duration limits, member-specific benefits, and applicable state or federal requirements.

    Policy Summary
    PayerUnitedHealthcare
    PolicyMenopur (menotropins) coverage for infertility treatment and fertility preservation
    Policy CodePolicy N/A
    Change TypeAnnual reviewbackground and references updated
    Effective DateSeptember 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization or notification for Menopur with documentation of the diagnosis, treatment purpose, applicable condition, setting, and coverage criteria.
    SourceLink
    POLICY UPDATE CHANGES

    The June 2026 annual review updated the background and references.

    3Clinical coverage pathways
    2 monthsAuthorization duration
    450 IU/dayMaximum ART dose without FSH
    14 days

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    Maximum ART duration without FSH
    225 IU/dayMaximum mixed-protocol dose
    150 IU/dayMaximum dose alone for induction or stimulation

    Clinical Coverage Criteria

    Ovarian stimulation

    Menopur is approved for ovarian stimulation when one of the following pathways is met.

    Qualifying ovarian stimulation pathway

    • Ovarian stimulation with ART

      • Required purpose: Diagnosis of infertility and use for the development of multiple follicles (ovarian stimulation).

      • Qualifying condition and setting

        • ART pathway: One of the following exists: diminished ovarian reserve, endometriosis, male factor infertility, tubal factor infertility, unexplained infertility, uterine factor infertility, ovulatory dysfunction, recurrent pregnancy loss, or failure to achieve conception with other treatment modalities; and treatment will be used in conjunction with assisted reproductive technology (ART).
        • IUI pathway: One of the following exists: diminished ovarian reserve, mild to moderate male factor infertility, minimal to mild endometriosis, unilateral tubal factor infertility, or unexplained infertility; and treatment will be used in conjunction with intrauterine insemination (IUI).

    • Fertility preservation

      • Fertility preservation use: Menopur is used for fertility preservation.
      • Gonadotoxic therapy: The individual will undergo gonadotoxic therapy, such as exposure to cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, or radiation therapy.
      • ART procedure: Treatment will be used as part of an assisted reproductive technology procedure, such as in vitro fertilization.

    Ovulation induction (off-label)

    Menopur is approved for off-label ovulation induction when all of the following are met.

    Ovulation induction

    • Ovulatory dysfunction: Diagnosis of ovulatory dysfunction.
    • Ovulatory presentation: One of the following exists: anovulation, oligo-ovulation, or amenorrhea.
    • Other causes addressed: Other specific causative factors, such as thyroid disease or hyperprolactinemia, have been excluded or treated.
    • Ovarian failure exclusion: Infertility is not due to primary ovarian failure.

    Male hypogonadotropic hypogonadism

    Menopur is approved for male hypogonadotropic hypogonadism when all of the following are met.

    • Hypogonadism diagnosis: One of the following diagnoses is documented: male primary hypogonadotropic hypogonadism or male secondary hypogonadotropic hypogonadism.
    • Treatment purpose: Treatment is for induction of spermatogenesis.
    • Testicular failure exclusion: Infertility is not due to primary testicular failure.

    Infertility is typically excluded from UnitedHealthcare coverage. Review the member’s specific benefit plan to determine whether infertility treatment is covered, along with any applicable state-specific requirements.

    Exceeding the stated clinically appropriate hMG dose or treatment duration has not been proven efficacious for pregnancy outcomes. For an ART cycle without an FSH product, the limit is 450 IU/day for no more than 14 days; maximum hMG dosing is 225 IU/day in a mixed hMG-plus-FSH stimulation protocol and 150 IU/day when hMG is used alone for ovulation induction or ovarian stimulation.

    Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization/notification is required for Menopur (menotropins). Submit the request under the applicable coverage pathway: ovarian stimulation, fertility preservation, off-label ovulation induction, or male hypogonadotropic hypogonadism.

    • Authorization is issued for 2 months for fertility-preservation requests and off-label ovulation-induction requests.
    Documentation Required

    Clinical Documentation Required

    Provide clinical documentation supporting the diagnosis, treatment purpose, qualifying condition, and treatment setting. Documentation must establish that the request meets the applicable pathway and that required exclusions or treatment relationships have been addressed.

    • Ovarian stimulation: document infertility, development of multiple follicles, the qualifying infertility condition, and use with assisted reproductive technology (ART) or intrauterine insemination (IUI).

    Clinical Background

    Gonadotropins, including human menopausal gonadotropin (hMG; Menopur), are used in infertility treatment to stimulate follicular development, induce ovulation, or induce spermatogenesis in selected patients. Menopur is indicated for the development of multiple follicles and pregnancy in ovulatory women participating in an assisted reproductive technology program. hMG may also be used for ovulation induction in women with ovulatory dysfunction, including polycystic ovary syndrome after failure of clomiphene, and for induction of spermatogenesis in men with primary or secondary hypogonadotropic hypogonadism when infertility is not due to primary testicular failure.

    Definitions

    Infertility
    DefinitionInfertility is the inability to achieve a successful pregnancy due to an individual's medical, sexual, or reproductive history.
    Female partner younger than 35Failure to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse.
    Female partner age 35 or olderFailure to achieve pregnancy after 6 months or more of regular unprotected sexual intercourse.
    Policy Summary
    PayerUnitedHealthcare
    PolicyMenopur (menotropins) coverage for infertility treatment and fertility preservation
    Policy CodePolicy N/A
    Change TypeAnnual reviewbackground and references updated
    Effective DateSeptember 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization or notification for Menopur with documentation of the diagnosis, treatment purpose, applicable condition, setting, and coverage criteria.
    SourceLink
    On This Page
    Clinical Coverage CriteriaAuthorization and Documentation RequirementsClinical BackgroundDefinitions
    Treatment purpose: Treatment is for induction of ovulation.
  1. Fertility preservation: document the need for fertility preservation, planned gonadotoxic therapy, and use as part of an ART procedure.
  2. Off-label ovulation induction: document ovulatory dysfunction, anovulation/oligo-ovulation/amenorrhea, exclusion or treatment of other causative factors, absence of primary ovarian failure, and the planned induction of ovulation.
  3. Male hypogonadotropic hypogonadism: document male primary or secondary hypogonadotropic hypogonadism, the purpose of inducing spermatogenesis, and absence of primary testicular failure.
    4. Denial Risk

    Ovarian Stimulation Criteria Not Met

    Ovarian stimulation requests are not supported when the required infertility diagnosis, treatment purpose, qualifying condition, or treatment setting is absent. Requests that do not meet one of the approved ART or IUI pathways may be denied.

    • The individual must have a diagnosis of infertility and Menopur must be used for development of multiple follicles (ovarian stimulation).
    • For use with ART, one of the following must exist: diminished ovarian reserve, endometriosis, male factor infertility, tubal factor infertility, unexplained infertility, uterine factor infertility, ovulatory dysfunction, recurrent pregnancy loss, or failure to achieve conception with other treatment modalities.
    • For use with IUI, one of the following must exist: diminished ovarian reserve, mild to moderate male factor infertility, minimal to mild endometriosis, unilateral tubal factor infertility, or unexplained infertility.
    • Requests lacking the required ART or IUI treatment setting are not supported.
    Denial Risk

    Fertility Preservation Criteria Not Met

    Fertility-preservation requests are not supported unless all required conditions are documented. Denial may result when the individual will not undergo gonadotoxic therapy or Menopur will not be used as part of an ART procedure.

    • The request must be for fertility preservation.
    • The individual must undergo gonadotoxic therapy, such as exposure to cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, or radiation therapy.
    • Menopur must be used as part of an ART procedure, such as in vitro fertilization.
    Denial Risk

    Ovulation Induction Criteria Not Met

    Off-label ovulation-induction requests are not supported unless all listed criteria are met. Requests are subject to denial when the documented condition, exclusions, treatment purpose, or infertility relationship does not satisfy the pathway.

    • There must be a diagnosis of ovulatory dysfunction and one of the following: anovulation, oligo-ovulation, or amenorrhea.
    • Other specific causative factors, such as thyroid disease or hyperprolactinemia, must have been excluded or treated.
    • Infertility must not be due to primary ovarian failure.
    • Menopur must be used for induction of ovulation.
    Denial Risk

    Male Hypogonadotropic Hypogonadism Criteria Not Met

    Requests for male hypogonadotropic hypogonadism are not supported unless the diagnosis and treatment purpose are documented and primary testicular failure is excluded.

    • The individual must have a diagnosis of male primary hypogonadotropic hypogonadism or male secondary hypogonadotropic hypogonadism.
    • Menopur must be used for induction of spermatogenesis.
    • Infertility must not be due to primary testicular failure.