Medical Policy In Vitro Fertilization (IVF) and Other Fertility Services CT Subject: In Vitro Fertilization (IVF) and Other Fertility Services CT Contents Background: ............................................................................................................................................................ 2 Prior Authorization: .................................................................................................................................................. 2 Authorization of Preimplantation Genetic Diagnosis (PGD) ....................................................................................... 3 POLICY AND COVERAGE CRITERIA FOR MEMBERS WITH UTERI/EGGS: ........................................................ 3 General eligibility criteria for Members with Uteri/Eggs ................................................................................................ 4 Ib. Assessment of ovary/uterus function: ........................................................................................................... 4 Ic. Assessment of contributory testicles/sperm: .................................................................................................. 4 II. Intrauterine Insemination (IUI) ........................................................................................................................ 5 IIa. Initiation to IUI ......................................................................................................................................... 5 IIb. Continuing IUI ........................................................................................................................................... 5 IIc. IUI after in vitro fertilization ........................................................................................................................ 5 IId. Conversion to IVF from IUI with hyper-response .......................................................................................... 5 III. Fertility services ............................................................................................................................................. 6 IIIa. In Vitro Fertilization (IVF) services ............................................................................................................. 6 In vitro fertilization service-specific criteria ..................................................................................................... 6 Cycle specifications and limitations ................................................................................................................ 6 Delivery protocols .................................................................................................................................... 6 Repeat cycle documentation ..................................................................................................................... 6 Service maximum ..................................................................................................................................... 6 Gamete and Zygote Intrafallopian Transfer (GIFT & ZIFT) ............................................................................... 6 IIIb. Donor egg (donor oocyte) ......................................................................................................................... 7 IIIc. Assisted Hatching (AH) .............................................................................................................................. 7 IIId. Reversal of prior sterilization ..................................................................................................................... 7 IIIe. Oocyte stimulation, retrieval, and fertilization .............................................................................................. 8 IIIf. Intracytoplasmic Sperm Injection (ICSI) ...................................................................................................... 8 IV. Cryopreservation of eggs and/or embryos ......................................................................................................... 8 IVa. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for a member in active (authorized) fertility treatment: ......................................................................................................................... 8 IVb. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) anticipatory to medical treatment expected to impact fertility: ............................................................................................................... 8 HPHC Medical Policy Page 1 of 15 In Vitro Fertilization (IVF) and Other Fertility Services CT VD29SEP21P HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations. Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information. IVc. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for members undergoing gender reassignment treatment: ....................................................................................................................... 9 POLICY AND COVERAGE CRITERIA FOR MEMBERS WITH TESTICLES/SPERM: ............................................... 9 I. Fertility services................................................................................................................................................ 9 Ia. Fertility confirmation requirement ................................................................................................................. 9 Ib. Intracytoplasmic Sperm Injection (ICSI) ....................................................................................................... 9 Ic. Donor sperm ............................................................................................................................................ 10 Id. Microsurgical Epididymal Sperm Aspiration (MESA) ...................................................................................... 10 Ie. Testicular Sperm Extraction (TESE) or Micro-TESE ....................................................................................... 10 If. Reversal of prior sterilization ....................................................................................................................... 10 II. Sperm collection and cryopreservation ............................................................................................................ 10 IIa. Cryopreservation related to fertility or medical treatment ............................................................................ 10 IIIb. Cryopreservation of eggs or sperm (including retrieval and up to one year of storage) for members undergoing gender reassignment treatment ...................................................................................................................... 11 Exclusions: ............................................................................................................................................................ 11 Guidelines and benchmarks: ................................................................................................................................... 12 Coding: ................................................................................................................................................................. 13 Billing Guidelines: .................................................................................................................................................. 13 References: ........................................................................................................................................................... 13 Background: This policy addresses fertility treatments and their uses. These services include in vitro fertilization (IVF), intrauterine insemination (IUI), gamete intrafallopian transfer, zygote intrafallopian transfer, tubal embryo transfer, gamete, embryo, and sperm cryopreservation, use of frozen embryos or eggs, oocyte and embryo donation, and gestational surrogacy. Infertility under age 35 is defined as the failure to achieve live birth when fertility would naturally be expected after 12 months or more of regular contraceptive-free sexual intercourse between an individual with ovaries/eggs and an individual with testes/sperm, as represented by the member and documented in the medical record. Infertility over age 35 is defined as the failure to achieve a live birth after 6 months or more of regular contraceptive-free sexual intercourse between an individual with ovaries/eggs and an individual with testes/sperm, as represented by the member and documented in the medical record. In cases where insemination is being used in lieu of intercourse, infertility is defined as the failure to achieve a live birth after 6 months of inseminations, either performed at home or in a supervised medical setting, as represented by the member and documented in the medical record. Fertility services rendered prior to diagnosis of clinical infertility are not covered. Prior Authorization: