In Vitro Fertilization (IVF) Reimbursement Policy
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This policy governs University Health Alliance (UHA/HSA) coverage, limitations, and administrative requirements for in vitro fertilization services for members, including eligibility criteria, exclusions, and prior authorization requirements.
No material clinical or coverage changes in this revision.
Coverage Criteria and Limits
Coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Member is legally married or joined in a civil union partnership according to the laws of the State of Hawaii (coverage subject to Limitations/Exclusions and Administrative Guidelines).
- The procedure is determined to be clinically appropriate and medically necessary as defined by Hawaii Revised Statutes §432E-1.4.
- For male–female couples: at least a five‑year history of infertility or infertility associated with one or more of the following conditions: endometriosis; in utero exposure to diethylstilbestrol (DES); blockage or surgical removal of one or both fallopian tubes; or abnormal male factors contributing to the infertility.
- For male–female couples: patient and partner have been unable to attain a successful pregnancy through other infertility treatments for which coverage is available.
- For female couples: failure to achieve pregnancy after three cycles of physician‑directed, appropriately timed intrauterine insemination (IUI). (IUI is a covered service.)
- The in vitro fertilization procedure is performed at a facility that conforms to ACOG guidelines for IVF clinics or ASRM minimal standards for IVF programs.
Additional coverage considerations
- Patients under 40 years with ovarian failure (premature ovarian insufficiency) may be eligible for coverage.
- Patients older than 44 years requesting IVF must demonstrate ovarian reserve (Day 3 FSH and Day 3 estradiol, antral follicle count within 6 months, and AMH within 6 months).
Limitations and exclusions
The following limitations and exclusions apply and restrict coverage for IVF and related services:
Quantity Limits and Code-Related Limits
Authorization, Submission, and Reconsideration
Prior authorization and submission
Prior authorization is required for IVF services. Appropriate documentation to support the clinical diagnosis must be submitted with the prior authorization request via UHA's online portal; if a portal login has not been established, contact UHA at 808-532-4000 to establish one.
- Submit supporting clinical documentation with the prior authorization request.
- Use UHA's online portal to request prior authorization; call 808-532-4000 to establish portal access if needed.
Medical necessity reconsideration
A provider may request that UHA reconsider the application of the medical necessity criteria by submitting supporting documentation for review.
- Provide relevant clinical records or evidence demonstrating why the medical necessity criteria should be reconsidered.
- Direct reconsideration requests and supporting documentation to UHA as described in the policy note.
Key Definitions
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