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Medical Policy: 04.02.01
Original Effective Date: November 1989
Reviewed: July 2007
Revised: May 2006
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Infertility is defined as failure to conceive after 12 months of unprotected intercourse, or the inability to sustain a successful pregnancy. For women over 34, infertility is established after six months of failure to conceive. 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).
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.
Prior Approval is recommended to document the medical necessity of IVF, GIFT and ICSI. Submit a prior approval now.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309
*Prior Approval is recommended for certain services referenced in this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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