Artificial Insemination Policy Number: Current Effective Date: MM.03.007 January 01, 2020 Lines of Business: Original Effective Date: HMO, PPO; FED 87 January 01, 2020 Place of Service: Precertification: Office; Outpatient Required, see Section IV

I. Description Artificial insemination (Intravaginal, Intracervical or Intrauterine insemination) involves the placement of whole semen or processed sperm into the female reproductive tract, which permits sperm-oocyte interaction in the absence of intercourse.

II. Policy Criteria Artificial insemination is covered (subject to Limitations and Administrative Guidelines) with or without medication for the management of infertility in any of the following situations: A. Abnormal male factors contributing to the infertility. B. Unexplained infertility. 1. For the purposes of this policy "infertility" is defined by the failure to achieve a successful pregnancy after twelve months or more of appropriate, timed unprotected intercourse for women thirty-five years or younger or six months for women over thirty-five years of age. C. Members age 44 years old and over must also demonstrate proof of ovarian reserve.

III. Limitations A. Insemination cycles with gonadotropins, is limited to three attempted medicated IUI cycles. For Member’s with successful medicated IUI cycle resulting in a live birth, additional cycles may be authorized as long as the Member continues to meet the definition of infertility. Members must have a diagnosis of infertility and meet the infertility coverage criteria within this document. B. Any donor related services, including but not limited to collection, storage, and processing of donor sperm are not covered. C. Gonadotropins for infertility are not covered without an authorization for infertility services. D. Infertility treatment medications are not reimbursed for members who do not meet our guidelines for infertility coverage or for anonymous donors.

IV. Administrative Guidelines A. Precertification is required for use of gonadotropins. To precertify, complete the Artificial Insemination Precertification and mail or fax the form, or use iExchange as indicated. Precertification is valid for one year. 1. Patients over 44 years old using gonadotropins injection with IUI, demonstration of ovarian reserve is required. Labs that are required as follows: a. Day 3 FSH b. Day 3 Estradiol c. Antral Follicle Count (AFC) within 6 months d. Anti- Mullerian hormone (AMH) level within 6 months Artificial Insemination 2

2. Follistim AQ is preferred gonadotropin. If prescribing Gonal-F, an additional precertification is required through CVS Caremark. 3. Maximum gonadotropin units is limited to 1500 IU per cycle attempt. B. Applicable codes: CPT Codes Description 58322 Artificial insemination; intra-uterine

Drug name HCPCS Codes Description NDC Gonal-F S0126 Injection, follitropin beta, 75 IU Yes Follistim-AQ S0128 Injection, Follitropin Alfa, 75 IU Yes C. The chart above identifies the HCPCS code that must be submitted on the claim form with NDC information to identify drug administration for artificial insemination.

V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician.

Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA’s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation.

VI. References 1. UptoDate. Evaluation and management of infertility in women of advancing age. Last updated April 29, 2019.