Infertility Benefit — Coverage Criteria
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This document describes Western Health Advantage's covered infertility services, copayment requirements, prior authorization and specific exclusions and limitations for members seeking infertility diagnosis and treatment.
No material clinical or coverage changes in this revision.
Covered and Excluded Infertility Services
Covered Services
Covered services (subject to 50% copayment and prior authorization):
All covered services require prior authorization and a 50% copayment.
Subject to 50% copayment and prior authorization.
Requires prior authorization and 50% copayment.
Must be medically indicated; prior authorization applies to covered infertility services generally.
Requires prior authorization and is subject to the 50% copayment.
The plan excludes services and supplies intended to reverse voluntary, surgically induced infertility, including procedures related to elective vasectomy or tubal ligation reversal attempts and infertility treatment following such reversal attempts. All services involved in surrogacy are excluded; this specifically includes, but is not limited to, embryo transfers. Services and supplies related to donor gametes are excluded: this includes services and supplies related to donor sperm, all services related to the sperm donor (including collection), and sperm storage. Frozen embryo transfers and Zygote Intra-Fallopian Transfer (ZIFT) are excluded. Intracytoplasmic Sperm Injection (ICSI) and procedures such as ovum transfer/transplants or uterine lavage for infertility diagnosis or treatment are excluded. Laboratory procedures for freezing or storing sperm, ova, and/or pre-embryos are excluded, as are specific items listed as experimental (for example, inoculation with a partner's white cells).
The policy treats experimental and/or investigational diagnostic studies, procedures, or drugs used to treat or determine the cause of infertility as excluded (not covered). Examples called out in the document include procedures considered experimental such as inoculation with a partner's white cells; the exclusion also broadly applies to any diagnostic studies, procedures, or pharmacologic treatments for infertility that are classified as experimental or investigational.
Prior Authorization, Documentation, and Provider Requirements
Prior authorization required
All covered infertility services must receive prior authorization from Western Health Advantage before services are rendered.
Prior authorization — language-assistance contact
Language-access notices reiterate that prior authorization is required for covered infertility services and provide contact information for language assistance.
- For interpreter services call 888.563.2250 or TTY 711.
Provider operational requirements
Document the member's diagnosis and obtain prior authorization; ensure exclusions are checked against the member's requested services before scheduling.
- Confirm and document the diagnosis of 'Infertility' per the plan definition.
- Obtain prior authorization for all covered infertility services.
No step therapy in language notices
Language-access notices include no step therapy requirements for infertility treatments.
- No step therapy requirements are mentioned in the provided language notices.
Document diagnosis and obtain prior authorization
The provider must document a diagnosis of 'Infertility' as defined by the plan; remember that prior authorization is required for all covered infertility services.
- Infertility is defined as inability to conceive after one year (or 6 months if >35) or failure after specified cycles of supervised artificial/donor insemination — document evidence accordingly.
- Obtain prior authorization before treatment.
Language assistance contact
Offer and arrange free language assistance for members; provide the required contact numbers for interpreter services.
- Call 888.563.2250 for interpreter services or TTY 711 for hearing impaired members.
Do not provide excluded infertility services
Do not provide or bill for excluded services: reversal of voluntary surgically induced infertility, surrogacy-related services, donor sperm/egg procurement or storage, frozen embryo transfers, ZIFT, ICSI, sperm storage, and other listed exclusions.
- Services and supplies to reverse voluntary, surgically induced infertility are excluded.
- All services involved in surrogacy, including embryo transfers, are excluded.
- Services and supplies related to donor sperm or sperm preservation for artificial insemination, frozen embryo transfers, ZIFT, ICSI, and sperm storage are excluded.
No other provider actions in language notices
No additional provider actions are stated in the language-access notices beyond offering free interpreter services and providing contact information.
Clinical Background and Policy Scope
For plan purposes, Infertility requires a documented diagnosis per the Copayment Summary. The policy context notes that all covered infertility services must receive prior authorization. Copayments for covered infertility services do not count toward the medical plan annual out-of-pocket maximum. Providers should ensure the member meets the plan definition of infertility and obtain prior authorization before proceeding with any covered infertility service.
Key Definitions and Language Assistance
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