When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
The provision of benefits for all services related to assisted reproductive technology is in accordance with the individual's benefit contract and varies by product and group. Therefore, individual member benefits must be verified. Some services may be subject to state mandates, medical necessity criteria, coverage limits, precertification or preapproval, or existing contractual exclusions.
Coverage eligibility for individuals may depend upon whether the individual has a history of a voluntary sterilization procedure(s) (e.g., vasectomy, tubal ligation).
IN VITRO FERTILIZATION (IVF)
In vitro fertilization (IVF) is considered medically necessary and, therefore, covered when an individual has a congenital absence or anomaly of reproductive organ(s).
In vitro fertilization (IVF) is considered medically necessary and, therefore, covered when all of the following criteria are met:
N46.01 Organic azoospermia
N46.021 Azoospermia due to drug therapy
N46.022 Azoospermia due to infection
N46.023 Azoospermia due to obstruction of efferent ducts
N46.024 Azoospermia due to radiation
N46.025 Azoospermia due to systemic disease
N46.029 Azoospermia due to other extratesticular causes
N46.11 Organic oligospermia
N46.121 Oligospermia due to drug therapy
N46.122 Oligospermia due to infection
N46.123 Oligospermia due to obstruction of efferent ducts
N46.124 Oligospermia due to radiation
N46.125 Oligospermia due to systemic disease
N46.129 Oligospermia due to other extratesticular causes
N46.8 Other male infertility
N46.9 Male infertility, unspecified
N97.0 Female infertility associated with anovulation
N97.1 Female infertility of tubal origin
N97.2 Female infertility of uterine origin
N97.8 Female infertility of other origin
N97.9 Female infertility, unspecified
Z31.7 Encounter for procreative management and counseling for gestational carrier
Z31.81 Encounter for male factor infertility in female patient
Z31.83 Encounter for assisted reproductive fertility procedure cycle
Z31.84 Encounter for fertility preservation procedure
Z31.9 Encounter for procreative management, unspecified
THE FOLLOWING CODES ARE USED TO REPRESENT EGG DONOR
Z52.810 Egg (Oocyte) donor under age 35, anonymous recipient
Z52.811 Egg (Oocyte) donor under age 35, designated recipient
Z52.812 Egg (Oocyte) donor age 35 and over, anonymous recipient
Z52.813 Egg (Oocyte) donor age 35 and over, designated recipient
Z52.819 Egg (Oocyte) donor, unspecified
THE FOLLOWING CODES ARE USED TO REPRESENT SPERM RETRIEVAL