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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity Health Alliance IUI Coverage & Prior Au…
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    CurrentUniversity Health Alliance (HSA)Policy MPP-0138-211209

    Artificial insemination (IUI) reimbursement

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    This document governs University Health Alliance (UHA/HSA) reimbursement and coverage criteria for artificial insemination, including intrauterine insemination (IUI), and outlines clinical criteria, limitations, exclusions, and administrative requirements for members and providers.

    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyArtificial insemination (IUI) reimbursement
    Policy CodePolicy MPP-0138-211209
    Change TypeNo material changes
    Effective DateJan 1, 2022
    Last ReviewJan 1, 2022
    Next Review Date
    Key ActionPrior authorization is not required for IUI except when the gonadotropin Gonal-f is used; submit authorization requests via UHA's online portal or contact UHA to establish login.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3max medicated IUI cycles
    150 IU/daymax FSH+LH per day

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    14 daysmax FSH+LH duration
    age 44+ovarian reserve proof threshold

    IUI Coverage Criteria

    IUI coverage criteria and limits

    Covered when ALL of the following medical and administrative criteria are met:

    ALL of the following

    • ALL of the following

      • ALL of the following

        • Clinical appropriateness per Hawaii Revised Statutes §432E-1.4 and medical criteria in this policy must be met
        • Diagnosis of infertility (see definition), abnormal male factor, or unexplained infertility
      • Members aged 44 years and older must demonstrate ovarian reserve with Day 3 FSH, Day 3 Estradiol, Antral Follicle Count (AFC) within 6 months, and Anti-Mullerian Hormone (AMH) within 6 months

    ANY of the following

    • Criteria in II.A are met
    • Documented tubal patency

    • ONE of

      • Three failed cycles using clomiphene citrate or letrozole
      • Diagnosis of hypothalamic dysfunction
      • Member is aged 41 years or older

    ALL of the following

    • Total FSH plus LH generally covered up to a maximum of 150 IU per day and up to a maximum of 14 days
    • Use of FSH and/or LH is limited to three unsuccessful medicated IUI cycles; additional cycles may be authorized after a live birth if infertility criteria continue to be met

    ALL of the following

    • Donor-related services (collection, storage, processing of donor sperm) are not covered
    • Artificial insemination services are not covered when a surrogate is used
    • Gonadotropins for infertility are not covered without an authorization for infertility services
    • IUI with FSH and/or LH for women aged 44 and over without documented ovarian reserve is not covered
    • Use of total FSH plus LH greater than 150 IU per day or beyond 14 days is generally not covered

    ALL of the following

    • Prior authorization is not required for IUI with or without medications except when Gonal-f is used; to request prior authorization submit via UHA's online portal or contact UHA to establish login
    • Supporting documentation must be legible, maintained in the patient's medical record, and available to UHA upon request

    Procedure Codes and Medication Limits

    IUI procedure codeCPTCovered
    58322Artificial insemination; intra-uterine
    FSH+LH dose and duration — covered limits
    Maximum daily doseTotal FSH+LH generally covered up to 150 IU per day
    Maximum durationCoverage generally limited to up to 14 days
    Not covered beyond limitsUse of total FSH+LH more than 150 IU/day or beyond 14 days is generally not covered
    Medicated IUI attempts with gonadotropins
    Maximum medicated IUI cyclesInsemination cycles with gonadotropins limited to three attempted medicated IUI cycles
    Additional cycles after live birthAdditional cycles may be authorized after a successful medicated IUI resulting in live birth if infertility criteria continue to be met

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Prior authorization required only for Gonal‑f; submission via UHA portal

    Prior authorization is not required for IUI with or without medications except when Gonal-f (a gonadotropin) is being used. To request prior authorization for Gonal-f, submit via UHA’s online portal; if your facility does not have a login, contact UHA at 808-532-4000 to establish one.

    • Ensure supporting documentation is legible and maintained in the patient’s medical record and available to UHA upon request.
    Documentation Required

    Keep supporting records available; request reconsideration via peer communication

    Maintain legible supporting documentation of medical necessity in the patient’s medical record and have it available to UHA upon request. If you disagree with an adverse coverage or medical necessity determination, request reconsideration through direct peer-to-peer communication and submit any additional supporting records.

    Key Definitions

    Artificial insemination — definition
    DefinitionArtificial insemination involves placement of whole semen or processed sperm into the female reproductive tract to permit sperm-oocyte interaction in the absence of intercourse (includes intravaginal, intracervical, or intrauterine insemination)
    Intravaginal/IntracervicalPlacement of semen or processed sperm into the vaginal or cervical canal
    Intrauterine insemination (IUI)Placement of processed sperm directly into the uterine cavity (see procedure code 58322)
    Infertility — definition and age thresholds
    General definitionInfertility: failure to achieve a successful pregnancy after 12 months of appropriate timed unprotected intercourse for women 35 years or younger, or 6 months for women over 35
    Age 41+ relevance
    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyArtificial insemination (IUI) reimbursement
    Policy CodePolicy MPP-0138-211209
    Change TypeNo material changes
    Effective DateJan 1, 2022
    Last ReviewJan 1, 2022
    Next Review Date
    Key ActionPrior authorization is not required for IUI except when the gonadotropin Gonal-f is used; submit authorization requests via UHA's online portal or contact UHA to establish login.
    SourceLink
    On This Page
    IUI Coverage CriteriaProcedure Codes and Medication LimitsAuthorization, Documentation, and Denial RisksKey Definitions
    FSH/LH-specific limitUse of FSH and/or LH is limited to three unsuccessful IUI cycles; additional FSH/LH cycles may be covered after a live birth if criteria remain met
  1. Keep documentation of infertility diagnosis and, when applicable, ovarian reserve testing (Day 3 FSH, Day 3 Estradiol, AFC within 6 months, AMH within 6 months).
  2. Use peer communication channels to request reconsideration and provide the supporting records referenced above.
    3. Denial Risk

    Risk of denial for gonadotropins without infertility authorization or exceeding limits

    Gonadotropins (FSH/LH) for infertility are not covered without an authorization for infertility services; use of FSH and/or LH is limited to three unsuccessful medicated IUI cycles and total FSH+LH above 150 IU/day or beyond 14 days is generally not covered. Unauthorized gonadotropin use risks claim denial.

    • IUI with FSH/LH for women aged 44+ is not covered without documented ovarian reserve.
    • After a successful medicated IUI resulting in live birth, additional cycles with gonadotropins may be authorized only if infertility criteria continue to be met.
    Member aged 41 years or older is an indication for IUI with FSH/LH when other criteria are met
    Age 44+ requirementMembers aged 44 and older must demonstrate proof of ovarian reserve (Day 3 FSH, Day 3 Estradiol, AFC within 6 months, and AMH within 6 months)
    Unexplained infertility — definition and required evaluations
    DefinitionUnexplained infertility: failure to diagnose the cause of infertility after evaluation including assessment of male factor infertility, ovulatory dysfunction, tubal patency, and when appropriate, ovarian reserve
    Required evaluationsEvaluation must include assessment of male factor, ovulatory function, and tubal patency; ovarian reserve assessment when appropriate
    Relation to coverageArtificial insemination is covered for unexplained infertility when policy clinical criteria are met
    Surrogate — definition
    DefinitionSurrogate: a woman who carries a child for a couple or single person with the intention of giving up that child once he/she is born
    Coverage implicationArtificial insemination services are not covered when a surrogate is used
    Related exclusionsDonor-related services and certain infertility treatments are also not covered for surrogate arrangements per policy limitations