Infertility Diagnosis and Treatment*

Medical Policy: 04.02.01 
Original Effective Date: November 1989 
Reviewed: April 2012 
Revised: May 2006 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy 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 will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

 According to the American Society for Reproductive Medicine (ASRM), infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of unprotected intercourse. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over the age of 35 years.  ASRM also defines recurrent pregnancy loss as a disease distinct from infertility and defined by two or more failed pregnancies. While each pregnancy loss deserves careful review as to cause, a thorough evaluation is warranted after three or more losses. For the purposes of determining when evaluation and treatment for infertility or for recurrent pregnancy loss is appropriate, ASRM states pregnancy is defined as a clinical pregnancy documented by ultrasonography or histopathologic examination.

Medical approaches to overcoming infertility include artificial insemination and stimulation of ovulation with medication.  More invasive techniques requiring the use of assisted reproductive technology (ART) involve the external manipulation of both egg and sperm and include in-vitro fertilization (IVF), gamete, zygote or embryo intrafallopian transfer (GIFT) and intracytoplasmic sperm injection (ICSI).

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Prior Approval: 

Prior approval is recommended to document the medical necessity of IVF, GIFT and ICSI. Submit a prior approval now. 

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Policy: 

Coverage for infertility diagnosis and treatment is a contract-specific benefit issue.

Contract benefits should be verified through Provider Services.

ART is not a covered benefit under the following circumstances:

• Infertility treatment needed as a result of prior voluntary sterilization or unsuccessful sterilization reversal procedure.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.

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Selected References: 

• Mitchell, AA. Infertility treatment - more risk and challenges. The New England Journal of Medicine 2002; 346:769-770.
• Lathi RB, Milki AA. Rate of aneuploidy in miscarriages following in vitro fertilization and intracytoplasmic sperm injection. Fertil Steril. 2004 May;81(5):1270.2.
• Combelles CM, Racowsky C. Assessment and optimization of oocyte quality during assisted reproductive technology treatment. Semin Reprod Med. 2005 Aug;23(3):277-84.
• Practice Committee, American Society for Reproductive Medicine. Fertility and Sterility® 2008;09:S60.
  

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Policy History: 

Date                                        Reason                              Action

May 2011                              Annual review                    Policy renewed

April 2012                             Annual review                    Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.