Aetna · Clinical coverage policy

Aetna Infertility coverage criteria

Aetna CPB 0327 covers infertility evaluation and treatment as medically necessary — basic male/female workup, ovulation induction, artificial/donor insemination, surgical correction, and (only under plans that include an Advanced Reproductive Technology benefit) IVF/GIFT/ZIFT, ICSI, assisted hatching, oocyte donation, and cryopreservation — but only after a documented age-based trial of egg-sperm contact (waived when inseminations would not be effective and IVF is the only option) and within day-3 FSH ovarian-reserve thresholds (under 19 mIU/mL). Precertification is explicitly required for the listed injectable infertility/gonadotropin drugs, and a long list of items (e.g., PGT-A, endometrial receptivity testing, sperm DNA fragmentation, DHEA, acupuncture, uterine transplant) are experimental/investigational or excluded, as are services after voluntary sterilization, embryo banking, and natural-menopause ART in women 40+.

Policy CPB 0327 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0327

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0327 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Infertility (CPT 58321), and what gets it denied?

Path
Aetna CPB 0327 covers infertility evaluation and treatment as medically necessary — basic male/female workup, ovulation induction, artificial/donor insemination, surgical correction, and (only under plans that include an Advanced Reproductive Technology benefit) IVF/GIFT/ZIFT, ICSI, assisted hatching, oocyte donation, and cryopreservation — but only after a documented age-based trial of egg-sperm contact (waived when inseminations would not be effective and IVF is the only option) and within day-3 FSH ovarian-reserve thresholds (under 19 mIU/mL). Precertification is explicitly required for the listed injectable infertility/gonadotropin drugs, and a long list of items (e.g., PGT-A, endometrial receptivity testing, sperm DNA fragmentation, DHEA, acupuncture, uterine transplant) are experimental/investigational or excluded, as are services after voluntary sterilization, embryo banking, and natural-menopause ART in women 40+. Coverage criteria include: Definition of infertility (ASRM 2023): the inability to achieve a successful pregnancy based on medical/sexual/reproductive history, age, physical findings, diagnostic testing, or any combination; OR the need for medical intervention (including donor gametes/embryos) to achieve a successful pregnancy as an individual or with a partner; OR in patients having regular unprotected intercourse with no known etiology suggesting impaired reproductive ability — evaluation initiated at 12 months if female partner under 35, at 6 months if female partner 35 or older. Definition shall NOT be used to deny/delay treatment based on relationship status or sexual orientation.; FEMALE basic infertility — history/physical including basal body temperature is medically necessary.; FEMALE laboratory studies medically necessary: anti-adrenal antibodies for apparently spontaneous primary ovarian insufficiency (premature ovarian failure); anti-sperm antibodies (immunobead or mixed antiglobulin method); Chlamydia trachomatis screening; fasting and 2-hour post 75g glucose challenge; lipid panel (total cholesterol, HDL, triglycerides); post-coital (Simms-Huhner) test of cervical mucus; rubella serology; testing for viral status (HIV, hepatitis B, hepatitis C).; FEMALE serum hormone levels medically necessary WHEN INDICATED: androgens (testosterone, androstenedione, DHEA-S) IF evidence of hyperandrogenism (hirsutism, acne, virilization) or ovulatory dysfunction.; FEMALE anti-mullerian hormone (AMH) medically necessary for: assessing menopausal status including premature ovarian failure; OR assessing ovarian status (ovarian reserve and responsiveness) as part of infertility/assisted reproduction evaluation such as IVF.; FEMALE gonadotropins (serum FSH, LH) medically necessary for women with irregular menstrual cycles or age-related ovulatory dysfunction (serum, not urinary, FSH is standard of care).; FEMALE hCG, progestins (progesterone, 17-hydroxyprogesterone), estrogens (estradiol) medically necessary [subject to Appendix medical-necessity limitations].; FEMALE prolactin medically necessary for women with an ovulatory disorder, galactorrhea, or a pituitary tumor.; FEMALE TSH medically necessary for women with symptoms of thyroid disease.; FEMALE ACTH medically necessary for ruling out Cushing's syndrome or Addison's disease in amenorrheic women.; FEMALE clomiphene citrate challenge test is medically necessary.; Karyotype testing medically necessary for couples with recurrent pregnancy loss (2 or more consecutive spontaneous abortions).; Artificial insemination (intrauterine, intracervical, or intravaginal) is medically necessary (some plans exclude artificial insemination or limit cycles per lifetime; plans vary).; FEMALE diagnostic procedures medically necessary when clinically indicated: CT or MR imaging of sella turcica IF prolactin elevated; endometrial biopsy; hysterosalpingography (HSG) or hysterosalpingo-contrast-ultrasonography (HyCoSy) to screen for tubal occlusion; hysteroscopy, salpingoscopy (falloscopy), hydrotubation; laparoscopy and chromotubation to assess tubal/pelvic pathology and follow up HSG abnormalities; sonohysterography to evaluate the uterus; ultrasound (ovarian, transvaginal, pelvic) [Appendix limits].; FEMALE monitoring of ovarian response to ovulatory stimulants medically necessary [Appendix limits]: estradiol, FSH, hCG quantitative, LH assay, progesterone, and serial ovarian ultrasounds for cycle monitoring.; FEMALE non-surgical treatments medically necessary: aromatase inhibitors (anastrozole, exemestane, letrozole); corticosteroids (dexamethasone, prednisone); estrogens (estrone, conjugated estrogens); hepatitis B vaccination of partners of people with hepatitis B; metformin for WHO Group II anovulatory disorders such as PCOS; progestins (oral, topical 8% gel, IM, or vaginal suppositories); rubella vaccination of susceptible women; tamoxifen or oral clomiphene citrate for ovulation induction.; FEMALE lutropin alfa (Luveris) medically necessary in combination with human FSH to stimulate follicular development in infertile hypo-gonadotropic hypo-gonadal women OR women with profound LH deficiency (LH less than 1.2 IU/L).; FEMALE prolactin inhibitors (bromocriptine, cabergoline, pergolide) medically necessary for ovulatory disorders due to hyperprolactinemia.; FEMALE infertility surgery medically necessary: hysteroscopic adhesiolysis for amenorrhea with intrauterine adhesions; hysteroscopic/fluoroscopic tubal cannulation (salpingostomy, fimbrioplasty), selective salpingography plus tubal catheterization, or transcervical balloon tuboplasty for proximal tubal obstruction; laparoscopic cystectomy for ovarian endometriomas; laparoscopy for pelvic pathology; resection/vaporization/fulguration of endometriosis implants plus adhesiolysis; removal of myomas, uterine septa, cysts, ovarian tumors, polyps.; FEMALE ovarian wedge resection or ovarian drilling medically necessary for WHO Group II ovulation disorders (e.g., PCOS) who have NOT responded to clomiphene citrate.; FEMALE surgical tubal reconstruction (unilateral/bilateral tubal microsurgery, laparoscopic tubal surgery, tuboplasty, tubal anastomosis) medically necessary for mid/distal tubal occlusion AND for proximal tubal disease where tubal cannulation has failed OR severe proximal disease precludes successful cannulation.; FEMALE tubal ligation (salpingectomy) medically necessary for women with hydrosalpinges contemplating IVF (improves chance of live birth before IVF).; Cervicectomy/trachelectomy is an acceptable alternative to hysterectomy for early-stage (IA2 or small IB1) cervical adenocarcinoma in women wishing to preserve fertility.; MALE basic infertility — history/physical examination required.; MALE laboratory studies medically necessary when indicated: anti-sperm antibodies (immunobead or mixed antiglobulin); cultures (prostatic secretion, semen, urine); serum hormone levels 17-hydroxyprogesterone, ACTH, estrogens (estradiol, estrone), gonadotropins (FSH, LH), growth hormone.; MALE androgens (testosterone, free testosterone) medically necessary; IF initial testosterone is low, a repeat measurement of total and free testosterone plus serum LH and prolactin is medically necessary.; MALE prolactin medically necessary for men with reduced sperm counts, galactorrhea, or pituitary tumors.; MALE sex hormone binding globulin (SHBG) medically necessary for men with signs/symptoms of hypogonadism and low-normal testosterone (NOT indicated in routine male infertility evaluation).; MALE TSH medically necessary for men with symptoms of thyroid disease.; MALE semen analysis (volume, pH, liquefaction, sperm concentration, total sperm number, motility, motile sperm/ejaculate, vitality, round cell differentiation, morphology, viscosity, agglutination) medically necessary; an abnormal result should be confirmed by at least one additional sample collected one or more weeks later.; MALE repeat semen analysis rules: up to 4 semen analyses if exposed to gonadotoxins with abnormal analysis; repeat if normal initial analysis and no pregnancy 4 months later; up to 2 repeat confirmatory tests if first abnormal and NOT exposed to gonadotoxins.; MALE semen leukocyte analysis (Endtz test, immunohistochemical staining) is medically necessary.; MALE seminal fructose is medically necessary (seminal alpha-glucosidase, zinc, citric acid, acid phosphatase are experimental/investigational/unproven).; MALE blood test for cytogenetic analysis (karyotype and FISH) medically necessary in men with severe deficits of semen quality or azoospermia (for consideration of ICSI).; MALE Y chromosome microdeletion analysis medically necessary in men with severe deficits of semen quality or azoospermia for consideration of ICSI (NOT routinely indicated before ICSI; subject to medical-necessity review).; MALE post-coital (Simms-Huhner) test of cervical mucus and sperm penetration assay (zona-free hamster egg penetration test) are medically necessary.; Karyotyping medically necessary for persons with recurrent pregnancy loss (2+ consecutive spontaneous abortions) AND for men with severe deficits in semen quality or nonobstructive azoospermia (for consideration of ICSI).; MALE testing for viral status (HIV, hepatitis B, hepatitis C) is medically necessary.; Genetic testing of CFTR mutations medically necessary for a man and his female partner IF the man has congenital absence of the vas deferens (CAVD).; MALE diagnostic procedures medically necessary: CT or MR imaging of sella turcica IF prolactin elevated; scrotal exploration; scrotal (testicular) ultrasound; testicular biopsy; transrectal ultrasound; vasography; venography.; MALE endocrine management medically necessary: androgens (testosterone) for documented androgen deficiency; anti-estrogens (tamoxifen) for men with elevated estrogen levels; clomiphene; corticosteroids (dexamethasone, prednisone); prolactin inhibitors (bromocriptine, cabergoline) for hyperprolactinemia; thyroid hormone replacement for thyroid deficiency.; MALE injectable endocrine management medically necessary: GnRH analogs and antagonists (LHRH); gonadotropins — hCG (Novarel, Ovidrel, Pregnyl, generic) and follitropins (follitropin alfa, follitropin beta). Many plans exclude infertility injectable medications.; MALE additional treatments medically necessary when indicated: antibiotics for identified infection (intra-prostatic antibiotic injection is experimental/investigational/unproven); varicocelectomy (spermatic vein ligation); spermatocelectomy and hydrocelectomy; vasovasostomy (most plans exclude reversal of sterilization including vasectomy reversal).; MALE surgical correction of epididymal blockage for obstructive azoospermia medically necessary: epididymectomy, epididymovasostomy, excision of epididymal tumors/cysts, epididymostomy.; MALE transurethral resection of ejaculatory ducts (TURED) medically necessary for obstruction of ejaculatory ducts.; MALE orchiopexy is medically necessary.; MALE alpha sympathomimetic agents (phenylephrine, imipramine) medically necessary for retrograde ejaculation.; MALE hepatitis B vaccination of partners of people with hepatitis B, and impotence treatments, are medically necessary.; Electroejaculation is medically necessary DME to overcome total anejaculation secondary to neurologic impairment, most commonly: diabetic neuropathy; prior retroperitoneal surgery (e.g., retroperitoneal lymphadenectomy for testicular cancer); spinal cord injury.; Donor insemination is medically necessary for ANY of: non-obstructive azoospermia; obstructive azoospermia; severe deficits in semen quality in couples not wishing to undergo ICSI; severe rhesus isoimmunization; high risk of transmitting a genetic disorder in the male partner to offspring; high risk of transmitting an infectious disease (e.g., HIV) to partner or offspring.; ART injectable medications medically necessary when appropriate for the ART procedure: GnRH analogs/antagonists (LHRH); gonadotropins — hCG, follitropins, menotropins (coverage limited to plans with an ART benefit; many plans exclude injectables or limit menotropin cycles per lifetime).; Ovulation induction (oral or injectable) medically necessary for women 37 years or younger unable to conceive after an appropriate trial of egg-sperm contact (oral OI may occur concurrently with the cycles of egg-sperm contact required to establish ART medical necessity).; Trial of egg-sperm contact (for OI/ART, documented in medical record): women UNDER 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 AND OLDER — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination. Applies to ALL individuals regardless of sexual orientation or availability of a reproductive partner. WAIVED for IVF when intravaginal/intrauterine/intracervical inseminations would not be expected to be effective and IVF is the only effective treatment.; IVF procedures medically necessary for persons meeting ANY ONE of Criteria 1-4.; IVF Criterion 1 (trial of ovulation induction): women 37 or younger — three cycles of oral or injectable ovulation induction (with or without inseminations); women 38 or older — NO trial of ovulation induction required.; IVF Criterion 2 (inseminations would not be effective; IVF is the only effective treatment) — ONE of: men with azoospermia or severe deficits in semen quality/quantity; OR women with tubal-factor infertility (bilateral tubal disease — salpingitis isthmica nodosum, tubal obstruction, absence, or hydrosalpinges); OR endometriosis stage 3 or 4; OR failure to conceive after pelvic surgery restoring normal anatomy (after regular egg-sperm contact 6 months if under 40, or 3 months if 40+); OR unilateral hydrosalpinx with failure to conceive after regular egg-sperm contact 12 months if under 40, or 6 months if 40+.; IVF Criterion 3 (inadvertent ovarian hyperstimulation): estradiol greater than 1,000 pg/mL PLUS greater than 3 follicles greater than 16 mm OR 4-8 follicles greater than 14 mm OR a larger number of smaller follicles, during preparation for a planned stimulated cycle, in women under 38 years.; IVF Criterion 4 (medical contraindication to pregnancy): women who have had a hysterectomy, or have a medical contraindication to pregnancy such as severe cardiac disease, or a condition requiring ingestion of a fetotoxic agent (some plans limit/exclude gestational surrogacy).; IVF with embryo transfer medically necessary when ART criteria met; includes embryo transfer (transcervical, including cryopreserved embryo transfer), frozen embryo transfer (FET), oocyte insemination in laboratory dish, oocyte retrieval via laparoscope or transvaginal needle aspiration, and sperm preparation/capacitation.; Freezing embryos not transferred during a stimulated IVF cycle and transferring before the next stimulated cycle may be medically necessary (minimizes ovulation induction and egg collection). Before a fresh ART cycle, previously frozen oocytes must be used; before the next fresh ART cycle, FET using reasonable-quality (grade B or equivalent) cryopreserved embryos must be used if available.; ICSI medically necessary for ANY of: severe deficits in semen quality/quantity including azoospermia or oligospermia (obstructive or non-obstructive); to fertilize frozen oocytes for IVF; persons facing iatrogenic infertility due to chemotherapy/pelvic radiotherapy/other gonadotoxic therapies/ovary or testicle removal for disease treatment; couples where a previous IVF cycle resulted in failed or poor fertilization (less than 50% fertilization). ICSI is NOT medically necessary in men whose abnormal sperm quality/quantity was rectified by varicocelectomy.; Assisted hatching medically necessary when the cycle plan is to transfer embryos into the uterus AND ANY ONE: embryo recipient age 38 or older; OR 2 or more failed embryo transfer attempts; OR thickened zona pellucida. (NOT medically necessary unless the cycle involves transfer of the embryo.); IVF cycles using either fresh or previously frozen oocytes are medically necessary when the ART cycle is medically necessary.; GIFT medically necessary as an alternative to IVF for women with female-factor infertility (member must have at least 1 patent fallopian tube); includes oocyte retrieval via laparoscope and immediate loading of eggs with sperm into a transfer catheter and insertion into the fallopian tube.; ZIFT, TET (tubal embryo transfer), and PROUST (pronuclear stage tubal embryo transfer) medically necessary as alternatives to IVF for women with female-factor infertility.; Specialized sperm retrieval techniques medically necessary to overcome anejaculation or azoospermia NOT due to a previous elective sterilization: vasal sperm aspiration, MESA, PESA, electroejaculation, TESA, microsurgical TESE, seminal vesicle sperm aspiration, sperm recovery from bladder/urine for retrograde ejaculation.; Oocyte donation medically necessary, when the infertile member is the intended recipient of resulting embryos, for ANY of: bilateral oophorectomy; gonadal dysgenesis including Turner syndrome; high risk of transmitting a genetic disorder from female partner to offspring; IVF treatment failure; ovarian failure following chemotherapy/radiotherapy; premature ovarian failure (failure of ovulation in woman younger than 40) — covered until the woman with POF is 45 years of age.; Cryopreservation of mature gametes (oocytes or sperm) or embryos medically necessary for persons facing iatrogenic infertility due to chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary/testicle removal for disease treatment.; Preimplantation genetic testing for monogenic disorders (PGT-M) — embryo biopsy and testing covered for persons with an ART benefit when PGT-M medical-necessity criteria in CPB 0358 are met.; Elective single embryo transfer (eSET) supported (ASRM 2021) for women under 35, or for transfer of a euploid embryo regardless of age; if such a woman has a single fresh embryo transfer that does not result in pregnancy (no documented fetal heartbeat) and her plan limits covered IVF cycles, Aetna will consider transfer of one cryopreserved embryo immediately following the unsuccessful fresh transfer as part of the same IVF cycle.; Ovarian reserve / FSH thresholds: women UNDER 40 — day 3 FSH must be less than 19 mIU/mL in their most recent test to use their own eggs in ART; women 40 AND OLDER — unmedicated day 3 FSH must be less than 19 mIU/mL in ALL prior tests to use their own eggs.; Premature ovarian failure (POF): women under 40 with day 3 FSH greater than 19 mIU/L are considered to have POF; ART (IVF) services medically necessary until they reach 45 years; women 40+ with POF may submit a NEW unmedicated day 3 FSH (even with a prior elevated level above 40) and qualify if the most recent test is less than 19 mIU/mL.; Ovarian reserve determination: measured by menstrual cycle day 3 serum FSH drawn after normal onset of menstruation (or after progesterone-induced menstruation for women who do not reliably menstruate); for women 39 and older ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months.. Applies to 27 codes: 58321, 58322, 58323, 58970, 58974, 58976, 76830, 76856, 76857, S4011, S4013, S4014, S4015, S4016, S4020, S4021, S4022, S4023, S4025, S4026, S4028, S4030, S4031, S4035, S4037, S4040, S4042.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Trial of egg-sperm contact documented in the medical record: women under 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 and older — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination.; Abnormal semen analysis confirmed by at least one additional sample collected one or more weeks after the first sample.; Day 3 FSH documentation: for women 39 and older, ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months; unmedicated day 3 FSH levels must be documented for ovarian-reserve determination (FSH drawn after normal onset of menstruation or progesterone-induced menstruation).; Statement of Medical Necessity (SMN) precertification forms required for certain infertility medications during precertification (see Specialty Pharmacy Precertification).; During precertification to bypass Specialty Pharmacy Guideline Management review of ART drugs: a medical authorization number and confirmation of approval of the infertility procedure under the medical benefit are required.; If initial male testosterone is low, document a repeat measurement of total and free testosterone plus serum LH and prolactin levels.; Recurrent pregnancy loss: document 2 or more consecutive spontaneous abortions (for karyotype testing).; Coverage subject to verification of the member's specific benefit plan terms (plans vary on sterilization exclusions, artificial insemination, cycle limits, injectable medications, oocyte donation fees, embryo/sperm cryopreservation and storage, and gestational surrogacy).
Trap
Policy exclusions and limitations: NOT COVERED — ART services for women 40 years of age and older with natural menopause (not medically necessary; natural menopause is not a disease, and using a woman's own eggs requires unmedicated day 3 FSH less than 19 mIU/mL in ALL prior tests).; NOT COVERED — IVF cycles for the sole purpose of embryo banking (none of the suitable embryos used in the current cycle; all frozen for future use) is not treatment of disease and is not covered.; NOT COVERED — cryopreservation/storage of embryos and gametes is not treatment of disease and is not covered, EXCEPT short-term cryopreservation of embryos necessary for contemporaneous use in persons under active fertility treatment, or use of cryopreserved embryos/mature gametes in persons facing infertility due to chemotherapy/other gonadotoxic therapies/gonad removal (some plans have a specific contractual exclusion of embryo and/or sperm cryopreservation and storage).; NOT COVERED — infertility services for persons who have undergone voluntary sterilization (tubal sterilization or vasectomy, with or without surgical reversal) or hysterectomy, because such services result from an elective procedure intended to prevent conception (most plans exclude this; includes sperm retrieval for men who have undergone vasectomy).; EXCLUDED (most plans) — reversal of sterilization procedures including vasectomy reversal.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — acupuncture for infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — bariatric surgery (for infertility).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — dehydroepiandrosterone (DHEA).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — direct intra-peritoneal insemination, fallopian tube sperm transfusion, intra-follicular insemination, and use of sperm precursors (round/elongated spermatid nuclei, immature sperm).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — drainage of ovarian cyst.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — DuoStim IVF protocol.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Early Embryo Viability Assessment (Eeva) test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — EmbryoGlue.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of CYP1A1 rs4646903 T>C genetic variations for risk of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of FAS/FASL genetic variations for risk of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of telomere length.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — fine needle aspiration ('mapping') of testes.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — FSH manipulation of women with elevated FSH levels (elevated FSH is a marker of reduced/age-related ovarian reserve; not proven to be affected by interventions to reduce FSH).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — germ cell transplantation or cultured testicular stem cells.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — adjuvant growth hormone treatment during ovulation induction (inadequate evidence it improves pregnancy rates).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — GIFT for persons with male factor infertility or unexplained infertility (insufficient evidence to recommend GIFT over IVF for these indications).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — hyperbaric oxygen therapy for treatment of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intralipid infusion for treatment of female infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intrauterine injection/infusion of platelet rich plasma (PRP) for treatment of female infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intravenous immunoglobulins for treatment of infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — in-vitro maturation of oocytes.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — leukocyte immunization (immunizing the female partner with the male partner's leukocytes).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — microdissection of the zona.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — parenteral administration of lipids.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — partial zonal dissection (PZD).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — preimplantation genetic testing for aneuploidy (PGT-A; formerly preimplantation genetic screening, PGS) for IVF optimization.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — physiological, hyaluronan-selected intracytoplasmic sperm injection (PICSI) (lacks reliable evidence of effectiveness compared to standard ICSI).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — stem cell therapy.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — subzonal sperm insertion (SUZI).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — uterine transplant.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — vaginal sildenafil.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — vasodilators for women undergoing fertility treatment.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — ZIFT for persons with male factor infertility or unexplained infertility (insufficient evidence to recommend ZIFT over IVF for these indications).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (tubal occlusion screening) — sonohysterosalpingography or saline hysterosalpingography (e.g., Femvue).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (tubal occlusion screening) — hysterosalpingo-foam sonography (HyFoSy) (e.g., ExEm Foam).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — acrosome reaction test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — Cap-Score Test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — Comet assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — computer-assisted sperm analysis (CASA) / computer-assisted sperm motion analysis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hemizona assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hyaluronan binding assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hypoosmotic swelling test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — in vitro testing of sperm penetration.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — reactive oxygen species (ROS) test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm chromatin assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm DNA condensation test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm DNA fragmentation assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm nucleus maturation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — TUNEL assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies for infertility) — Analysis of Infectious Chronic Endometritis (ALICE) (Igenomix).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Anti-CarP (anti-carbamylated proteins) panel.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antinuclear antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiovarian antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphospholipid antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidic acid antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylethanolamine antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylglycerol antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylinositol antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylserine antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiprothrombin antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithrombin III (ATIII) activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithrombin III (ATIII) antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithyroglobulin antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — embryotoxicity assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Endometrial Microbiome Metagenomic Analysis (EMMA) (Igenomix).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — endometrial receptivity testing (endometrial receptivity analysis [Igenomix], endometrial receptivity array [ERA], integrin testing, beta-3 integrin test).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Factor V Leiden coagulation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Factor V Leiden mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — HLA genotyping (A, B, C, DR, DQ).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — homocysteine.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — methylenetetrahydrofolate reductase (MTHFR).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Oxidative Stress Adduct Test (OSA).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Plasminogen Activator Inhibitor-I activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Plasminogen Activator Inhibitor-I (PAI-1) antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein C activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein C antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein S activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein S antigen (free or total).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — prothrombin (Factor II) mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — uterine and endometrial receptivity testing (Endometrial function test [EFT; cyclin E and p27] and E-tegrity).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — measurement of natural killer (NK) cell activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — reproductive immunophenotyping.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — serum inhibin B measurement (value in assessing ovarian reserve is uncertain).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Th1/Th2 intracellular cytokine assay (Th1/Th2 ratio).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — uBiome SmartJane screen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — vaginal microbiota.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — urinary FSH testing (serum, not urinary, FSH is the standard of care for determining menopausal status).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — seminal alpha-glucosidase, zinc, citric acid, and acid phosphatase.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intra-prostatic antibiotic injection.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — routine use of gamete cryopreservation in lieu of embryo cryopreservation; gamete cryopreservation to circumvent reproductive aging in healthy persons; cryopreservation of immature gametes; laser-assisted necrotic blastomere removal from cryopreserved embryos.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — sperm cryopreservation to circumvent reproductive aging in healthy men.; NOT MEDICALLY NECESSARY — ICSI in men whose abnormal sperm quality or quantity had been rectified by varicocelectomy.; NOT MEDICALLY NECESSARY — assisted hatching unless the cycle involves transfer of the embryo into the uterus. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0327 — Infertility

Coverage criteria

  • Definition of infertility (ASRM 2023): the inability to achieve a successful pregnancy based on medical/sexual/reproductive history, age, physical findings, diagnostic testing, or any combination; OR the need for medical intervention (including donor gametes/embryos) to achieve a successful pregnancy as an individual or with a partner; OR in patients having regular unprotected intercourse with no known etiology suggesting impaired reproductive ability — evaluation initiated at 12 months if female partner under 35, at 6 months if female partner 35 or older. Definition shall NOT be used to deny/delay treatment based on relationship status or sexual orientation.
  • FEMALE basic infertility — history/physical including basal body temperature is medically necessary.
  • FEMALE laboratory studies medically necessary: anti-adrenal antibodies for apparently spontaneous primary ovarian insufficiency (premature ovarian failure); anti-sperm antibodies (immunobead or mixed antiglobulin method); Chlamydia trachomatis screening; fasting and 2-hour post 75g glucose challenge; lipid panel (total cholesterol, HDL, triglycerides); post-coital (Simms-Huhner) test of cervical mucus; rubella serology; testing for viral status (HIV, hepatitis B, hepatitis C).
  • FEMALE serum hormone levels medically necessary WHEN INDICATED: androgens (testosterone, androstenedione, DHEA-S) IF evidence of hyperandrogenism (hirsutism, acne, virilization) or ovulatory dysfunction.
  • FEMALE anti-mullerian hormone (AMH) medically necessary for: assessing menopausal status including premature ovarian failure; OR assessing ovarian status (ovarian reserve and responsiveness) as part of infertility/assisted reproduction evaluation such as IVF.
  • FEMALE gonadotropins (serum FSH, LH) medically necessary for women with irregular menstrual cycles or age-related ovulatory dysfunction (serum, not urinary, FSH is standard of care).
  • FEMALE hCG, progestins (progesterone, 17-hydroxyprogesterone), estrogens (estradiol) medically necessary [subject to Appendix medical-necessity limitations].
  • FEMALE prolactin medically necessary for women with an ovulatory disorder, galactorrhea, or a pituitary tumor.
  • FEMALE TSH medically necessary for women with symptoms of thyroid disease.
  • FEMALE ACTH medically necessary for ruling out Cushing's syndrome or Addison's disease in amenorrheic women.
  • FEMALE clomiphene citrate challenge test is medically necessary.
  • Karyotype testing medically necessary for couples with recurrent pregnancy loss (2 or more consecutive spontaneous abortions).
  • Artificial insemination (intrauterine, intracervical, or intravaginal) is medically necessary (some plans exclude artificial insemination or limit cycles per lifetime; plans vary).
  • FEMALE diagnostic procedures medically necessary when clinically indicated: CT or MR imaging of sella turcica IF prolactin elevated; endometrial biopsy; hysterosalpingography (HSG) or hysterosalpingo-contrast-ultrasonography (HyCoSy) to screen for tubal occlusion; hysteroscopy, salpingoscopy (falloscopy), hydrotubation; laparoscopy and chromotubation to assess tubal/pelvic pathology and follow up HSG abnormalities; sonohysterography to evaluate the uterus; ultrasound (ovarian, transvaginal, pelvic) [Appendix limits].
  • FEMALE monitoring of ovarian response to ovulatory stimulants medically necessary [Appendix limits]: estradiol, FSH, hCG quantitative, LH assay, progesterone, and serial ovarian ultrasounds for cycle monitoring.
  • FEMALE non-surgical treatments medically necessary: aromatase inhibitors (anastrozole, exemestane, letrozole); corticosteroids (dexamethasone, prednisone); estrogens (estrone, conjugated estrogens); hepatitis B vaccination of partners of people with hepatitis B; metformin for WHO Group II anovulatory disorders such as PCOS; progestins (oral, topical 8% gel, IM, or vaginal suppositories); rubella vaccination of susceptible women; tamoxifen or oral clomiphene citrate for ovulation induction.
  • FEMALE lutropin alfa (Luveris) medically necessary in combination with human FSH to stimulate follicular development in infertile hypo-gonadotropic hypo-gonadal women OR women with profound LH deficiency (LH less than 1.2 IU/L).
  • FEMALE prolactin inhibitors (bromocriptine, cabergoline, pergolide) medically necessary for ovulatory disorders due to hyperprolactinemia.
  • FEMALE infertility surgery medically necessary: hysteroscopic adhesiolysis for amenorrhea with intrauterine adhesions; hysteroscopic/fluoroscopic tubal cannulation (salpingostomy, fimbrioplasty), selective salpingography plus tubal catheterization, or transcervical balloon tuboplasty for proximal tubal obstruction; laparoscopic cystectomy for ovarian endometriomas; laparoscopy for pelvic pathology; resection/vaporization/fulguration of endometriosis implants plus adhesiolysis; removal of myomas, uterine septa, cysts, ovarian tumors, polyps.
  • FEMALE ovarian wedge resection or ovarian drilling medically necessary for WHO Group II ovulation disorders (e.g., PCOS) who have NOT responded to clomiphene citrate.
  • FEMALE surgical tubal reconstruction (unilateral/bilateral tubal microsurgery, laparoscopic tubal surgery, tuboplasty, tubal anastomosis) medically necessary for mid/distal tubal occlusion AND for proximal tubal disease where tubal cannulation has failed OR severe proximal disease precludes successful cannulation.
  • FEMALE tubal ligation (salpingectomy) medically necessary for women with hydrosalpinges contemplating IVF (improves chance of live birth before IVF).
  • Cervicectomy/trachelectomy is an acceptable alternative to hysterectomy for early-stage (IA2 or small IB1) cervical adenocarcinoma in women wishing to preserve fertility.
  • MALE basic infertility — history/physical examination required.
  • MALE laboratory studies medically necessary when indicated: anti-sperm antibodies (immunobead or mixed antiglobulin); cultures (prostatic secretion, semen, urine); serum hormone levels 17-hydroxyprogesterone, ACTH, estrogens (estradiol, estrone), gonadotropins (FSH, LH), growth hormone.
  • MALE androgens (testosterone, free testosterone) medically necessary; IF initial testosterone is low, a repeat measurement of total and free testosterone plus serum LH and prolactin is medically necessary.
  • MALE prolactin medically necessary for men with reduced sperm counts, galactorrhea, or pituitary tumors.
  • MALE sex hormone binding globulin (SHBG) medically necessary for men with signs/symptoms of hypogonadism and low-normal testosterone (NOT indicated in routine male infertility evaluation).
  • MALE TSH medically necessary for men with symptoms of thyroid disease.
  • MALE semen analysis (volume, pH, liquefaction, sperm concentration, total sperm number, motility, motile sperm/ejaculate, vitality, round cell differentiation, morphology, viscosity, agglutination) medically necessary; an abnormal result should be confirmed by at least one additional sample collected one or more weeks later.
  • MALE repeat semen analysis rules: up to 4 semen analyses if exposed to gonadotoxins with abnormal analysis; repeat if normal initial analysis and no pregnancy 4 months later; up to 2 repeat confirmatory tests if first abnormal and NOT exposed to gonadotoxins.
  • MALE semen leukocyte analysis (Endtz test, immunohistochemical staining) is medically necessary.
  • MALE seminal fructose is medically necessary (seminal alpha-glucosidase, zinc, citric acid, acid phosphatase are experimental/investigational/unproven).
  • MALE blood test for cytogenetic analysis (karyotype and FISH) medically necessary in men with severe deficits of semen quality or azoospermia (for consideration of ICSI).
  • MALE Y chromosome microdeletion analysis medically necessary in men with severe deficits of semen quality or azoospermia for consideration of ICSI (NOT routinely indicated before ICSI; subject to medical-necessity review).
  • MALE post-coital (Simms-Huhner) test of cervical mucus and sperm penetration assay (zona-free hamster egg penetration test) are medically necessary.
  • Karyotyping medically necessary for persons with recurrent pregnancy loss (2+ consecutive spontaneous abortions) AND for men with severe deficits in semen quality or nonobstructive azoospermia (for consideration of ICSI).
  • MALE testing for viral status (HIV, hepatitis B, hepatitis C) is medically necessary.
  • Genetic testing of CFTR mutations medically necessary for a man and his female partner IF the man has congenital absence of the vas deferens (CAVD).
  • MALE diagnostic procedures medically necessary: CT or MR imaging of sella turcica IF prolactin elevated; scrotal exploration; scrotal (testicular) ultrasound; testicular biopsy; transrectal ultrasound; vasography; venography.
  • MALE endocrine management medically necessary: androgens (testosterone) for documented androgen deficiency; anti-estrogens (tamoxifen) for men with elevated estrogen levels; clomiphene; corticosteroids (dexamethasone, prednisone); prolactin inhibitors (bromocriptine, cabergoline) for hyperprolactinemia; thyroid hormone replacement for thyroid deficiency.
  • MALE injectable endocrine management medically necessary: GnRH analogs and antagonists (LHRH); gonadotropins — hCG (Novarel, Ovidrel, Pregnyl, generic) and follitropins (follitropin alfa, follitropin beta). Many plans exclude infertility injectable medications.
  • MALE additional treatments medically necessary when indicated: antibiotics for identified infection (intra-prostatic antibiotic injection is experimental/investigational/unproven); varicocelectomy (spermatic vein ligation); spermatocelectomy and hydrocelectomy; vasovasostomy (most plans exclude reversal of sterilization including vasectomy reversal).
  • MALE surgical correction of epididymal blockage for obstructive azoospermia medically necessary: epididymectomy, epididymovasostomy, excision of epididymal tumors/cysts, epididymostomy.
  • MALE transurethral resection of ejaculatory ducts (TURED) medically necessary for obstruction of ejaculatory ducts.
  • MALE orchiopexy is medically necessary.
  • MALE alpha sympathomimetic agents (phenylephrine, imipramine) medically necessary for retrograde ejaculation.
  • MALE hepatitis B vaccination of partners of people with hepatitis B, and impotence treatments, are medically necessary.
  • Electroejaculation is medically necessary DME to overcome total anejaculation secondary to neurologic impairment, most commonly: diabetic neuropathy; prior retroperitoneal surgery (e.g., retroperitoneal lymphadenectomy for testicular cancer); spinal cord injury.
  • Donor insemination is medically necessary for ANY of: non-obstructive azoospermia; obstructive azoospermia; severe deficits in semen quality in couples not wishing to undergo ICSI; severe rhesus isoimmunization; high risk of transmitting a genetic disorder in the male partner to offspring; high risk of transmitting an infectious disease (e.g., HIV) to partner or offspring.
  • ART injectable medications medically necessary when appropriate for the ART procedure: GnRH analogs/antagonists (LHRH); gonadotropins — hCG, follitropins, menotropins (coverage limited to plans with an ART benefit; many plans exclude injectables or limit menotropin cycles per lifetime).
  • Ovulation induction (oral or injectable) medically necessary for women 37 years or younger unable to conceive after an appropriate trial of egg-sperm contact (oral OI may occur concurrently with the cycles of egg-sperm contact required to establish ART medical necessity).
  • Trial of egg-sperm contact (for OI/ART, documented in medical record): women UNDER 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 AND OLDER — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination. Applies to ALL individuals regardless of sexual orientation or availability of a reproductive partner. WAIVED for IVF when intravaginal/intrauterine/intracervical inseminations would not be expected to be effective and IVF is the only effective treatment.
  • IVF procedures medically necessary for persons meeting ANY ONE of Criteria 1-4.
  • IVF Criterion 1 (trial of ovulation induction): women 37 or younger — three cycles of oral or injectable ovulation induction (with or without inseminations); women 38 or older — NO trial of ovulation induction required.
  • IVF Criterion 2 (inseminations would not be effective; IVF is the only effective treatment) — ONE of: men with azoospermia or severe deficits in semen quality/quantity; OR women with tubal-factor infertility (bilateral tubal disease — salpingitis isthmica nodosum, tubal obstruction, absence, or hydrosalpinges); OR endometriosis stage 3 or 4; OR failure to conceive after pelvic surgery restoring normal anatomy (after regular egg-sperm contact 6 months if under 40, or 3 months if 40+); OR unilateral hydrosalpinx with failure to conceive after regular egg-sperm contact 12 months if under 40, or 6 months if 40+.
  • IVF Criterion 3 (inadvertent ovarian hyperstimulation): estradiol greater than 1,000 pg/mL PLUS greater than 3 follicles greater than 16 mm OR 4-8 follicles greater than 14 mm OR a larger number of smaller follicles, during preparation for a planned stimulated cycle, in women under 38 years.
  • IVF Criterion 4 (medical contraindication to pregnancy): women who have had a hysterectomy, or have a medical contraindication to pregnancy such as severe cardiac disease, or a condition requiring ingestion of a fetotoxic agent (some plans limit/exclude gestational surrogacy).
  • IVF with embryo transfer medically necessary when ART criteria met; includes embryo transfer (transcervical, including cryopreserved embryo transfer), frozen embryo transfer (FET), oocyte insemination in laboratory dish, oocyte retrieval via laparoscope or transvaginal needle aspiration, and sperm preparation/capacitation.
  • Freezing embryos not transferred during a stimulated IVF cycle and transferring before the next stimulated cycle may be medically necessary (minimizes ovulation induction and egg collection). Before a fresh ART cycle, previously frozen oocytes must be used; before the next fresh ART cycle, FET using reasonable-quality (grade B or equivalent) cryopreserved embryos must be used if available.
  • ICSI medically necessary for ANY of: severe deficits in semen quality/quantity including azoospermia or oligospermia (obstructive or non-obstructive); to fertilize frozen oocytes for IVF; persons facing iatrogenic infertility due to chemotherapy/pelvic radiotherapy/other gonadotoxic therapies/ovary or testicle removal for disease treatment; couples where a previous IVF cycle resulted in failed or poor fertilization (less than 50% fertilization). ICSI is NOT medically necessary in men whose abnormal sperm quality/quantity was rectified by varicocelectomy.
  • Assisted hatching medically necessary when the cycle plan is to transfer embryos into the uterus AND ANY ONE: embryo recipient age 38 or older; OR 2 or more failed embryo transfer attempts; OR thickened zona pellucida. (NOT medically necessary unless the cycle involves transfer of the embryo.)
  • IVF cycles using either fresh or previously frozen oocytes are medically necessary when the ART cycle is medically necessary.
  • GIFT medically necessary as an alternative to IVF for women with female-factor infertility (member must have at least 1 patent fallopian tube); includes oocyte retrieval via laparoscope and immediate loading of eggs with sperm into a transfer catheter and insertion into the fallopian tube.
  • ZIFT, TET (tubal embryo transfer), and PROUST (pronuclear stage tubal embryo transfer) medically necessary as alternatives to IVF for women with female-factor infertility.
  • Specialized sperm retrieval techniques medically necessary to overcome anejaculation or azoospermia NOT due to a previous elective sterilization: vasal sperm aspiration, MESA, PESA, electroejaculation, TESA, microsurgical TESE, seminal vesicle sperm aspiration, sperm recovery from bladder/urine for retrograde ejaculation.
  • Oocyte donation medically necessary, when the infertile member is the intended recipient of resulting embryos, for ANY of: bilateral oophorectomy; gonadal dysgenesis including Turner syndrome; high risk of transmitting a genetic disorder from female partner to offspring; IVF treatment failure; ovarian failure following chemotherapy/radiotherapy; premature ovarian failure (failure of ovulation in woman younger than 40) — covered until the woman with POF is 45 years of age.
  • Cryopreservation of mature gametes (oocytes or sperm) or embryos medically necessary for persons facing iatrogenic infertility due to chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary/testicle removal for disease treatment.
  • Preimplantation genetic testing for monogenic disorders (PGT-M) — embryo biopsy and testing covered for persons with an ART benefit when PGT-M medical-necessity criteria in CPB 0358 are met.
  • Elective single embryo transfer (eSET) supported (ASRM 2021) for women under 35, or for transfer of a euploid embryo regardless of age; if such a woman has a single fresh embryo transfer that does not result in pregnancy (no documented fetal heartbeat) and her plan limits covered IVF cycles, Aetna will consider transfer of one cryopreserved embryo immediately following the unsuccessful fresh transfer as part of the same IVF cycle.
  • Ovarian reserve / FSH thresholds: women UNDER 40 — day 3 FSH must be less than 19 mIU/mL in their most recent test to use their own eggs in ART; women 40 AND OLDER — unmedicated day 3 FSH must be less than 19 mIU/mL in ALL prior tests to use their own eggs.
  • Premature ovarian failure (POF): women under 40 with day 3 FSH greater than 19 mIU/L are considered to have POF; ART (IVF) services medically necessary until they reach 45 years; women 40+ with POF may submit a NEW unmedicated day 3 FSH (even with a prior elevated level above 40) and qualify if the most recent test is less than 19 mIU/mL.
  • Ovarian reserve determination: measured by menstrual cycle day 3 serum FSH drawn after normal onset of menstruation (or after progesterone-induced menstruation for women who do not reliably menstruate); for women 39 and older ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Trial of egg-sperm contact documented in the medical record: women under 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 and older — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination.
  • Abnormal semen analysis confirmed by at least one additional sample collected one or more weeks after the first sample.
  • Day 3 FSH documentation: for women 39 and older, ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months; unmedicated day 3 FSH levels must be documented for ovarian-reserve determination (FSH drawn after normal onset of menstruation or progesterone-induced menstruation).
  • Statement of Medical Necessity (SMN) precertification forms required for certain infertility medications during precertification (see Specialty Pharmacy Precertification).
  • During precertification to bypass Specialty Pharmacy Guideline Management review of ART drugs: a medical authorization number and confirmation of approval of the infertility procedure under the medical benefit are required.
  • If initial male testosterone is low, document a repeat measurement of total and free testosterone plus serum LH and prolactin levels.
  • Recurrent pregnancy loss: document 2 or more consecutive spontaneous abortions (for karyotype testing).
  • Coverage subject to verification of the member's specific benefit plan terms (plans vary on sterilization exclusions, artificial insemination, cycle limits, injectable medications, oocyte donation fees, embryo/sperm cryopreservation and storage, and gestational surrogacy).

Frequently asked questions

When does Aetna cover Infertility (CPT 58321), and what gets it denied?
Aetna CPB 0327 covers infertility evaluation and treatment as medically necessary — basic male/female workup, ovulation induction, artificial/donor insemination, surgical correction, and (only under plans that include an Advanced Reproductive Technology benefit) IVF/GIFT/ZIFT, ICSI, assisted hatching, oocyte donation, and cryopreservation — but only after a documented age-based trial of egg-sperm contact (waived when inseminations would not be effective and IVF is the only option) and within day-3 FSH ovarian-reserve thresholds (under 19 mIU/mL). Precertification is explicitly required for the listed injectable infertility/gonadotropin drugs, and a long list of items (e.g., PGT-A, endometrial receptivity testing, sperm DNA fragmentation, DHEA, acupuncture, uterine transplant) are experimental/investigational or excluded, as are services after voluntary sterilization, embryo banking, and natural-menopause ART in women 40+. Coverage criteria include: Definition of infertility (ASRM 2023): the inability to achieve a successful pregnancy based on medical/sexual/reproductive history, age, physical findings, diagnostic testing, or any combination; OR the need for medical intervention (including donor gametes/embryos) to achieve a successful pregnancy as an individual or with a partner; OR in patients having regular unprotected intercourse with no known etiology suggesting impaired reproductive ability — evaluation initiated at 12 months if female partner under 35, at 6 months if female partner 35 or older. Definition shall NOT be used to deny/delay treatment based on relationship status or sexual orientation.; FEMALE basic infertility — history/physical including basal body temperature is medically necessary.; FEMALE laboratory studies medically necessary: anti-adrenal antibodies for apparently spontaneous primary ovarian insufficiency (premature ovarian failure); anti-sperm antibodies (immunobead or mixed antiglobulin method); Chlamydia trachomatis screening; fasting and 2-hour post 75g glucose challenge; lipid panel (total cholesterol, HDL, triglycerides); post-coital (Simms-Huhner) test of cervical mucus; rubella serology; testing for viral status (HIV, hepatitis B, hepatitis C).; FEMALE serum hormone levels medically necessary WHEN INDICATED: androgens (testosterone, androstenedione, DHEA-S) IF evidence of hyperandrogenism (hirsutism, acne, virilization) or ovulatory dysfunction.; FEMALE anti-mullerian hormone (AMH) medically necessary for: assessing menopausal status including premature ovarian failure; OR assessing ovarian status (ovarian reserve and responsiveness) as part of infertility/assisted reproduction evaluation such as IVF.; FEMALE gonadotropins (serum FSH, LH) medically necessary for women with irregular menstrual cycles or age-related ovulatory dysfunction (serum, not urinary, FSH is standard of care).; FEMALE hCG, progestins (progesterone, 17-hydroxyprogesterone), estrogens (estradiol) medically necessary [subject to Appendix medical-necessity limitations].; FEMALE prolactin medically necessary for women with an ovulatory disorder, galactorrhea, or a pituitary tumor.; FEMALE TSH medically necessary for women with symptoms of thyroid disease.; FEMALE ACTH medically necessary for ruling out Cushing's syndrome or Addison's disease in amenorrheic women.; FEMALE clomiphene citrate challenge test is medically necessary.; Karyotype testing medically necessary for couples with recurrent pregnancy loss (2 or more consecutive spontaneous abortions).; Artificial insemination (intrauterine, intracervical, or intravaginal) is medically necessary (some plans exclude artificial insemination or limit cycles per lifetime; plans vary).; FEMALE diagnostic procedures medically necessary when clinically indicated: CT or MR imaging of sella turcica IF prolactin elevated; endometrial biopsy; hysterosalpingography (HSG) or hysterosalpingo-contrast-ultrasonography (HyCoSy) to screen for tubal occlusion; hysteroscopy, salpingoscopy (falloscopy), hydrotubation; laparoscopy and chromotubation to assess tubal/pelvic pathology and follow up HSG abnormalities; sonohysterography to evaluate the uterus; ultrasound (ovarian, transvaginal, pelvic) [Appendix limits].; FEMALE monitoring of ovarian response to ovulatory stimulants medically necessary [Appendix limits]: estradiol, FSH, hCG quantitative, LH assay, progesterone, and serial ovarian ultrasounds for cycle monitoring.; FEMALE non-surgical treatments medically necessary: aromatase inhibitors (anastrozole, exemestane, letrozole); corticosteroids (dexamethasone, prednisone); estrogens (estrone, conjugated estrogens); hepatitis B vaccination of partners of people with hepatitis B; metformin for WHO Group II anovulatory disorders such as PCOS; progestins (oral, topical 8% gel, IM, or vaginal suppositories); rubella vaccination of susceptible women; tamoxifen or oral clomiphene citrate for ovulation induction.; FEMALE lutropin alfa (Luveris) medically necessary in combination with human FSH to stimulate follicular development in infertile hypo-gonadotropic hypo-gonadal women OR women with profound LH deficiency (LH less than 1.2 IU/L).; FEMALE prolactin inhibitors (bromocriptine, cabergoline, pergolide) medically necessary for ovulatory disorders due to hyperprolactinemia.; FEMALE infertility surgery medically necessary: hysteroscopic adhesiolysis for amenorrhea with intrauterine adhesions; hysteroscopic/fluoroscopic tubal cannulation (salpingostomy, fimbrioplasty), selective salpingography plus tubal catheterization, or transcervical balloon tuboplasty for proximal tubal obstruction; laparoscopic cystectomy for ovarian endometriomas; laparoscopy for pelvic pathology; resection/vaporization/fulguration of endometriosis implants plus adhesiolysis; removal of myomas, uterine septa, cysts, ovarian tumors, polyps.; FEMALE ovarian wedge resection or ovarian drilling medically necessary for WHO Group II ovulation disorders (e.g., PCOS) who have NOT responded to clomiphene citrate.; FEMALE surgical tubal reconstruction (unilateral/bilateral tubal microsurgery, laparoscopic tubal surgery, tuboplasty, tubal anastomosis) medically necessary for mid/distal tubal occlusion AND for proximal tubal disease where tubal cannulation has failed OR severe proximal disease precludes successful cannulation.; FEMALE tubal ligation (salpingectomy) medically necessary for women with hydrosalpinges contemplating IVF (improves chance of live birth before IVF).; Cervicectomy/trachelectomy is an acceptable alternative to hysterectomy for early-stage (IA2 or small IB1) cervical adenocarcinoma in women wishing to preserve fertility.; MALE basic infertility — history/physical examination required.; MALE laboratory studies medically necessary when indicated: anti-sperm antibodies (immunobead or mixed antiglobulin); cultures (prostatic secretion, semen, urine); serum hormone levels 17-hydroxyprogesterone, ACTH, estrogens (estradiol, estrone), gonadotropins (FSH, LH), growth hormone.; MALE androgens (testosterone, free testosterone) medically necessary; IF initial testosterone is low, a repeat measurement of total and free testosterone plus serum LH and prolactin is medically necessary.; MALE prolactin medically necessary for men with reduced sperm counts, galactorrhea, or pituitary tumors.; MALE sex hormone binding globulin (SHBG) medically necessary for men with signs/symptoms of hypogonadism and low-normal testosterone (NOT indicated in routine male infertility evaluation).; MALE TSH medically necessary for men with symptoms of thyroid disease.; MALE semen analysis (volume, pH, liquefaction, sperm concentration, total sperm number, motility, motile sperm/ejaculate, vitality, round cell differentiation, morphology, viscosity, agglutination) medically necessary; an abnormal result should be confirmed by at least one additional sample collected one or more weeks later.; MALE repeat semen analysis rules: up to 4 semen analyses if exposed to gonadotoxins with abnormal analysis; repeat if normal initial analysis and no pregnancy 4 months later; up to 2 repeat confirmatory tests if first abnormal and NOT exposed to gonadotoxins.; MALE semen leukocyte analysis (Endtz test, immunohistochemical staining) is medically necessary.; MALE seminal fructose is medically necessary (seminal alpha-glucosidase, zinc, citric acid, acid phosphatase are experimental/investigational/unproven).; MALE blood test for cytogenetic analysis (karyotype and FISH) medically necessary in men with severe deficits of semen quality or azoospermia (for consideration of ICSI).; MALE Y chromosome microdeletion analysis medically necessary in men with severe deficits of semen quality or azoospermia for consideration of ICSI (NOT routinely indicated before ICSI; subject to medical-necessity review).; MALE post-coital (Simms-Huhner) test of cervical mucus and sperm penetration assay (zona-free hamster egg penetration test) are medically necessary.; Karyotyping medically necessary for persons with recurrent pregnancy loss (2+ consecutive spontaneous abortions) AND for men with severe deficits in semen quality or nonobstructive azoospermia (for consideration of ICSI).; MALE testing for viral status (HIV, hepatitis B, hepatitis C) is medically necessary.; Genetic testing of CFTR mutations medically necessary for a man and his female partner IF the man has congenital absence of the vas deferens (CAVD).; MALE diagnostic procedures medically necessary: CT or MR imaging of sella turcica IF prolactin elevated; scrotal exploration; scrotal (testicular) ultrasound; testicular biopsy; transrectal ultrasound; vasography; venography.; MALE endocrine management medically necessary: androgens (testosterone) for documented androgen deficiency; anti-estrogens (tamoxifen) for men with elevated estrogen levels; clomiphene; corticosteroids (dexamethasone, prednisone); prolactin inhibitors (bromocriptine, cabergoline) for hyperprolactinemia; thyroid hormone replacement for thyroid deficiency.; MALE injectable endocrine management medically necessary: GnRH analogs and antagonists (LHRH); gonadotropins — hCG (Novarel, Ovidrel, Pregnyl, generic) and follitropins (follitropin alfa, follitropin beta). Many plans exclude infertility injectable medications.; MALE additional treatments medically necessary when indicated: antibiotics for identified infection (intra-prostatic antibiotic injection is experimental/investigational/unproven); varicocelectomy (spermatic vein ligation); spermatocelectomy and hydrocelectomy; vasovasostomy (most plans exclude reversal of sterilization including vasectomy reversal).; MALE surgical correction of epididymal blockage for obstructive azoospermia medically necessary: epididymectomy, epididymovasostomy, excision of epididymal tumors/cysts, epididymostomy.; MALE transurethral resection of ejaculatory ducts (TURED) medically necessary for obstruction of ejaculatory ducts.; MALE orchiopexy is medically necessary.; MALE alpha sympathomimetic agents (phenylephrine, imipramine) medically necessary for retrograde ejaculation.; MALE hepatitis B vaccination of partners of people with hepatitis B, and impotence treatments, are medically necessary.; Electroejaculation is medically necessary DME to overcome total anejaculation secondary to neurologic impairment, most commonly: diabetic neuropathy; prior retroperitoneal surgery (e.g., retroperitoneal lymphadenectomy for testicular cancer); spinal cord injury.; Donor insemination is medically necessary for ANY of: non-obstructive azoospermia; obstructive azoospermia; severe deficits in semen quality in couples not wishing to undergo ICSI; severe rhesus isoimmunization; high risk of transmitting a genetic disorder in the male partner to offspring; high risk of transmitting an infectious disease (e.g., HIV) to partner or offspring.; ART injectable medications medically necessary when appropriate for the ART procedure: GnRH analogs/antagonists (LHRH); gonadotropins — hCG, follitropins, menotropins (coverage limited to plans with an ART benefit; many plans exclude injectables or limit menotropin cycles per lifetime).; Ovulation induction (oral or injectable) medically necessary for women 37 years or younger unable to conceive after an appropriate trial of egg-sperm contact (oral OI may occur concurrently with the cycles of egg-sperm contact required to establish ART medical necessity).; Trial of egg-sperm contact (for OI/ART, documented in medical record): women UNDER 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 AND OLDER — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination. Applies to ALL individuals regardless of sexual orientation or availability of a reproductive partner. WAIVED for IVF when intravaginal/intrauterine/intracervical inseminations would not be expected to be effective and IVF is the only effective treatment.; IVF procedures medically necessary for persons meeting ANY ONE of Criteria 1-4.; IVF Criterion 1 (trial of ovulation induction): women 37 or younger — three cycles of oral or injectable ovulation induction (with or without inseminations); women 38 or older — NO trial of ovulation induction required.; IVF Criterion 2 (inseminations would not be effective; IVF is the only effective treatment) — ONE of: men with azoospermia or severe deficits in semen quality/quantity; OR women with tubal-factor infertility (bilateral tubal disease — salpingitis isthmica nodosum, tubal obstruction, absence, or hydrosalpinges); OR endometriosis stage 3 or 4; OR failure to conceive after pelvic surgery restoring normal anatomy (after regular egg-sperm contact 6 months if under 40, or 3 months if 40+); OR unilateral hydrosalpinx with failure to conceive after regular egg-sperm contact 12 months if under 40, or 6 months if 40+.; IVF Criterion 3 (inadvertent ovarian hyperstimulation): estradiol greater than 1,000 pg/mL PLUS greater than 3 follicles greater than 16 mm OR 4-8 follicles greater than 14 mm OR a larger number of smaller follicles, during preparation for a planned stimulated cycle, in women under 38 years.; IVF Criterion 4 (medical contraindication to pregnancy): women who have had a hysterectomy, or have a medical contraindication to pregnancy such as severe cardiac disease, or a condition requiring ingestion of a fetotoxic agent (some plans limit/exclude gestational surrogacy).; IVF with embryo transfer medically necessary when ART criteria met; includes embryo transfer (transcervical, including cryopreserved embryo transfer), frozen embryo transfer (FET), oocyte insemination in laboratory dish, oocyte retrieval via laparoscope or transvaginal needle aspiration, and sperm preparation/capacitation.; Freezing embryos not transferred during a stimulated IVF cycle and transferring before the next stimulated cycle may be medically necessary (minimizes ovulation induction and egg collection). Before a fresh ART cycle, previously frozen oocytes must be used; before the next fresh ART cycle, FET using reasonable-quality (grade B or equivalent) cryopreserved embryos must be used if available.; ICSI medically necessary for ANY of: severe deficits in semen quality/quantity including azoospermia or oligospermia (obstructive or non-obstructive); to fertilize frozen oocytes for IVF; persons facing iatrogenic infertility due to chemotherapy/pelvic radiotherapy/other gonadotoxic therapies/ovary or testicle removal for disease treatment; couples where a previous IVF cycle resulted in failed or poor fertilization (less than 50% fertilization). ICSI is NOT medically necessary in men whose abnormal sperm quality/quantity was rectified by varicocelectomy.; Assisted hatching medically necessary when the cycle plan is to transfer embryos into the uterus AND ANY ONE: embryo recipient age 38 or older; OR 2 or more failed embryo transfer attempts; OR thickened zona pellucida. (NOT medically necessary unless the cycle involves transfer of the embryo.); IVF cycles using either fresh or previously frozen oocytes are medically necessary when the ART cycle is medically necessary.; GIFT medically necessary as an alternative to IVF for women with female-factor infertility (member must have at least 1 patent fallopian tube); includes oocyte retrieval via laparoscope and immediate loading of eggs with sperm into a transfer catheter and insertion into the fallopian tube.; ZIFT, TET (tubal embryo transfer), and PROUST (pronuclear stage tubal embryo transfer) medically necessary as alternatives to IVF for women with female-factor infertility.; Specialized sperm retrieval techniques medically necessary to overcome anejaculation or azoospermia NOT due to a previous elective sterilization: vasal sperm aspiration, MESA, PESA, electroejaculation, TESA, microsurgical TESE, seminal vesicle sperm aspiration, sperm recovery from bladder/urine for retrograde ejaculation.; Oocyte donation medically necessary, when the infertile member is the intended recipient of resulting embryos, for ANY of: bilateral oophorectomy; gonadal dysgenesis including Turner syndrome; high risk of transmitting a genetic disorder from female partner to offspring; IVF treatment failure; ovarian failure following chemotherapy/radiotherapy; premature ovarian failure (failure of ovulation in woman younger than 40) — covered until the woman with POF is 45 years of age.; Cryopreservation of mature gametes (oocytes or sperm) or embryos medically necessary for persons facing iatrogenic infertility due to chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary/testicle removal for disease treatment.; Preimplantation genetic testing for monogenic disorders (PGT-M) — embryo biopsy and testing covered for persons with an ART benefit when PGT-M medical-necessity criteria in CPB 0358 are met.; Elective single embryo transfer (eSET) supported (ASRM 2021) for women under 35, or for transfer of a euploid embryo regardless of age; if such a woman has a single fresh embryo transfer that does not result in pregnancy (no documented fetal heartbeat) and her plan limits covered IVF cycles, Aetna will consider transfer of one cryopreserved embryo immediately following the unsuccessful fresh transfer as part of the same IVF cycle.; Ovarian reserve / FSH thresholds: women UNDER 40 — day 3 FSH must be less than 19 mIU/mL in their most recent test to use their own eggs in ART; women 40 AND OLDER — unmedicated day 3 FSH must be less than 19 mIU/mL in ALL prior tests to use their own eggs.; Premature ovarian failure (POF): women under 40 with day 3 FSH greater than 19 mIU/L are considered to have POF; ART (IVF) services medically necessary until they reach 45 years; women 40+ with POF may submit a NEW unmedicated day 3 FSH (even with a prior elevated level above 40) and qualify if the most recent test is less than 19 mIU/mL.; Ovarian reserve determination: measured by menstrual cycle day 3 serum FSH drawn after normal onset of menstruation (or after progesterone-induced menstruation for women who do not reliably menstruate); for women 39 and older ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months.. Applies to 27 codes: 58321, 58322, 58323, 58970, 58974, 58976, 76830, 76856, 76857, S4011, S4013, S4014, S4015, S4016, S4020, S4021, S4022, S4023, S4025, S4026, S4028, S4030, S4031, S4035, S4037, S4040, S4042. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Trial of egg-sperm contact documented in the medical record: women under 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 and older — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination.; Abnormal semen analysis confirmed by at least one additional sample collected one or more weeks after the first sample.; Day 3 FSH documentation: for women 39 and older, ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months; unmedicated day 3 FSH levels must be documented for ovarian-reserve determination (FSH drawn after normal onset of menstruation or progesterone-induced menstruation).; Statement of Medical Necessity (SMN) precertification forms required for certain infertility medications during precertification (see Specialty Pharmacy Precertification).; During precertification to bypass Specialty Pharmacy Guideline Management review of ART drugs: a medical authorization number and confirmation of approval of the infertility procedure under the medical benefit are required.; If initial male testosterone is low, document a repeat measurement of total and free testosterone plus serum LH and prolactin levels.; Recurrent pregnancy loss: document 2 or more consecutive spontaneous abortions (for karyotype testing).; Coverage subject to verification of the member's specific benefit plan terms (plans vary on sterilization exclusions, artificial insemination, cycle limits, injectable medications, oocyte donation fees, embryo/sperm cryopreservation and storage, and gestational surrogacy). Policy exclusions and limitations: NOT COVERED — ART services for women 40 years of age and older with natural menopause (not medically necessary; natural menopause is not a disease, and using a woman's own eggs requires unmedicated day 3 FSH less than 19 mIU/mL in ALL prior tests).; NOT COVERED — IVF cycles for the sole purpose of embryo banking (none of the suitable embryos used in the current cycle; all frozen for future use) is not treatment of disease and is not covered.; NOT COVERED — cryopreservation/storage of embryos and gametes is not treatment of disease and is not covered, EXCEPT short-term cryopreservation of embryos necessary for contemporaneous use in persons under active fertility treatment, or use of cryopreserved embryos/mature gametes in persons facing infertility due to chemotherapy/other gonadotoxic therapies/gonad removal (some plans have a specific contractual exclusion of embryo and/or sperm cryopreservation and storage).; NOT COVERED — infertility services for persons who have undergone voluntary sterilization (tubal sterilization or vasectomy, with or without surgical reversal) or hysterectomy, because such services result from an elective procedure intended to prevent conception (most plans exclude this; includes sperm retrieval for men who have undergone vasectomy).; EXCLUDED (most plans) — reversal of sterilization procedures including vasectomy reversal.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — acupuncture for infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — bariatric surgery (for infertility).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — dehydroepiandrosterone (DHEA).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — direct intra-peritoneal insemination, fallopian tube sperm transfusion, intra-follicular insemination, and use of sperm precursors (round/elongated spermatid nuclei, immature sperm).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — drainage of ovarian cyst.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — DuoStim IVF protocol.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Early Embryo Viability Assessment (Eeva) test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — EmbryoGlue.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of CYP1A1 rs4646903 T>C genetic variations for risk of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of FAS/FASL genetic variations for risk of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of telomere length.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — fine needle aspiration ('mapping') of testes.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — FSH manipulation of women with elevated FSH levels (elevated FSH is a marker of reduced/age-related ovarian reserve; not proven to be affected by interventions to reduce FSH).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — germ cell transplantation or cultured testicular stem cells.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — adjuvant growth hormone treatment during ovulation induction (inadequate evidence it improves pregnancy rates).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — GIFT for persons with male factor infertility or unexplained infertility (insufficient evidence to recommend GIFT over IVF for these indications).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — hyperbaric oxygen therapy for treatment of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intralipid infusion for treatment of female infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intrauterine injection/infusion of platelet rich plasma (PRP) for treatment of female infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intravenous immunoglobulins for treatment of infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — in-vitro maturation of oocytes.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — leukocyte immunization (immunizing the female partner with the male partner's leukocytes).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — microdissection of the zona.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — parenteral administration of lipids.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — partial zonal dissection (PZD).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — preimplantation genetic testing for aneuploidy (PGT-A; formerly preimplantation genetic screening, PGS) for IVF optimization.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — physiological, hyaluronan-selected intracytoplasmic sperm injection (PICSI) (lacks reliable evidence of effectiveness compared to standard ICSI).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — stem cell therapy.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — subzonal sperm insertion (SUZI).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — uterine transplant.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — vaginal sildenafil.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — vasodilators for women undergoing fertility treatment.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — ZIFT for persons with male factor infertility or unexplained infertility (insufficient evidence to recommend ZIFT over IVF for these indications).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (tubal occlusion screening) — sonohysterosalpingography or saline hysterosalpingography (e.g., Femvue).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (tubal occlusion screening) — hysterosalpingo-foam sonography (HyFoSy) (e.g., ExEm Foam).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — acrosome reaction test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — Cap-Score Test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — Comet assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — computer-assisted sperm analysis (CASA) / computer-assisted sperm motion analysis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hemizona assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hyaluronan binding assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hypoosmotic swelling test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — in vitro testing of sperm penetration.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — reactive oxygen species (ROS) test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm chromatin assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm DNA condensation test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm DNA fragmentation assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm nucleus maturation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — TUNEL assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies for infertility) — Analysis of Infectious Chronic Endometritis (ALICE) (Igenomix).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Anti-CarP (anti-carbamylated proteins) panel.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antinuclear antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiovarian antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphospholipid antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidic acid antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylethanolamine antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylglycerol antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylinositol antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylserine antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiprothrombin antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithrombin III (ATIII) activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithrombin III (ATIII) antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithyroglobulin antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — embryotoxicity assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Endometrial Microbiome Metagenomic Analysis (EMMA) (Igenomix).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — endometrial receptivity testing (endometrial receptivity analysis [Igenomix], endometrial receptivity array [ERA], integrin testing, beta-3 integrin test).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Factor V Leiden coagulation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Factor V Leiden mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — HLA genotyping (A, B, C, DR, DQ).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — homocysteine.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — methylenetetrahydrofolate reductase (MTHFR).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Oxidative Stress Adduct Test (OSA).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Plasminogen Activator Inhibitor-I activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Plasminogen Activator Inhibitor-I (PAI-1) antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein C activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein C antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein S activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein S antigen (free or total).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — prothrombin (Factor II) mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — uterine and endometrial receptivity testing (Endometrial function test [EFT; cyclin E and p27] and E-tegrity).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — measurement of natural killer (NK) cell activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — reproductive immunophenotyping.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — serum inhibin B measurement (value in assessing ovarian reserve is uncertain).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Th1/Th2 intracellular cytokine assay (Th1/Th2 ratio).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — uBiome SmartJane screen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — vaginal microbiota.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — urinary FSH testing (serum, not urinary, FSH is the standard of care for determining menopausal status).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — seminal alpha-glucosidase, zinc, citric acid, and acid phosphatase.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intra-prostatic antibiotic injection.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — routine use of gamete cryopreservation in lieu of embryo cryopreservation; gamete cryopreservation to circumvent reproductive aging in healthy persons; cryopreservation of immature gametes; laser-assisted necrotic blastomere removal from cryopreserved embryos.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — sperm cryopreservation to circumvent reproductive aging in healthy men.; NOT MEDICALLY NECESSARY — ICSI in men whose abnormal sperm quality or quantity had been rectified by varicocelectomy.; NOT MEDICALLY NECESSARY — assisted hatching unless the cycle involves transfer of the embryo into the uterus. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Infertility?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: Trial of egg-sperm contact documented in the medical record: women under 35 — 12 months of regular intravaginal inseminations OR 4 cycles of timed intrauterine/intracervical inseminations; women 35 and older — 6 months of regular intravaginal inseminations OR 3 cycles of timed intrauterine/intracervical insemination.; Abnormal semen analysis confirmed by at least one additional sample collected one or more weeks after the first sample.; Day 3 FSH documentation: for women 39 and older, ovarian responsiveness determined by day 3 FSH obtained within the prior 6 months; unmedicated day 3 FSH levels must be documented for ovarian-reserve determination (FSH drawn after normal onset of menstruation or progesterone-induced menstruation).; Statement of Medical Necessity (SMN) precertification forms required for certain infertility medications during precertification (see Specialty Pharmacy Precertification).; During precertification to bypass Specialty Pharmacy Guideline Management review of ART drugs: a medical authorization number and confirmation of approval of the infertility procedure under the medical benefit are required.; If initial male testosterone is low, document a repeat measurement of total and free testosterone plus serum LH and prolactin levels.; Recurrent pregnancy loss: document 2 or more consecutive spontaneous abortions (for karyotype testing).; Coverage subject to verification of the member's specific benefit plan terms (plans vary on sterilization exclusions, artificial insemination, cycle limits, injectable medications, oocyte donation fees, embryo/sperm cryopreservation and storage, and gestational surrogacy).
What does Aetna exclude for Infertility?
Policy exclusions and limitations: NOT COVERED — ART services for women 40 years of age and older with natural menopause (not medically necessary; natural menopause is not a disease, and using a woman's own eggs requires unmedicated day 3 FSH less than 19 mIU/mL in ALL prior tests).; NOT COVERED — IVF cycles for the sole purpose of embryo banking (none of the suitable embryos used in the current cycle; all frozen for future use) is not treatment of disease and is not covered.; NOT COVERED — cryopreservation/storage of embryos and gametes is not treatment of disease and is not covered, EXCEPT short-term cryopreservation of embryos necessary for contemporaneous use in persons under active fertility treatment, or use of cryopreserved embryos/mature gametes in persons facing infertility due to chemotherapy/other gonadotoxic therapies/gonad removal (some plans have a specific contractual exclusion of embryo and/or sperm cryopreservation and storage).; NOT COVERED — infertility services for persons who have undergone voluntary sterilization (tubal sterilization or vasectomy, with or without surgical reversal) or hysterectomy, because such services result from an elective procedure intended to prevent conception (most plans exclude this; includes sperm retrieval for men who have undergone vasectomy).; EXCLUDED (most plans) — reversal of sterilization procedures including vasectomy reversal.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — acupuncture for infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — bariatric surgery (for infertility).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — dehydroepiandrosterone (DHEA).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — direct intra-peritoneal insemination, fallopian tube sperm transfusion, intra-follicular insemination, and use of sperm precursors (round/elongated spermatid nuclei, immature sperm).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — drainage of ovarian cyst.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — DuoStim IVF protocol.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — Early Embryo Viability Assessment (Eeva) test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — EmbryoGlue.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of CYP1A1 rs4646903 T>C genetic variations for risk of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of FAS/FASL genetic variations for risk of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — evaluation of telomere length.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — fine needle aspiration ('mapping') of testes.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — FSH manipulation of women with elevated FSH levels (elevated FSH is a marker of reduced/age-related ovarian reserve; not proven to be affected by interventions to reduce FSH).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — germ cell transplantation or cultured testicular stem cells.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — adjuvant growth hormone treatment during ovulation induction (inadequate evidence it improves pregnancy rates).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — GIFT for persons with male factor infertility or unexplained infertility (insufficient evidence to recommend GIFT over IVF for these indications).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — hyperbaric oxygen therapy for treatment of male infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intralipid infusion for treatment of female infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intrauterine injection/infusion of platelet rich plasma (PRP) for treatment of female infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intravenous immunoglobulins for treatment of infertility.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — in-vitro maturation of oocytes.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — leukocyte immunization (immunizing the female partner with the male partner's leukocytes).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — microdissection of the zona.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — parenteral administration of lipids.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — partial zonal dissection (PZD).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — preimplantation genetic testing for aneuploidy (PGT-A; formerly preimplantation genetic screening, PGS) for IVF optimization.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — physiological, hyaluronan-selected intracytoplasmic sperm injection (PICSI) (lacks reliable evidence of effectiveness compared to standard ICSI).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — stem cell therapy.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — subzonal sperm insertion (SUZI).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — uterine transplant.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — vaginal sildenafil.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — vasodilators for women undergoing fertility treatment.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — ZIFT for persons with male factor infertility or unexplained infertility (insufficient evidence to recommend ZIFT over IVF for these indications).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (tubal occlusion screening) — sonohysterosalpingography or saline hysterosalpingography (e.g., Femvue).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (tubal occlusion screening) — hysterosalpingo-foam sonography (HyFoSy) (e.g., ExEm Foam).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — acrosome reaction test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — Cap-Score Test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — Comet assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — computer-assisted sperm analysis (CASA) / computer-assisted sperm motion analysis.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hemizona assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hyaluronan binding assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — hypoosmotic swelling test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — in vitro testing of sperm penetration.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — reactive oxygen species (ROS) test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm chromatin assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm DNA condensation test.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm DNA fragmentation assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — sperm nucleus maturation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (sperm function tests) — TUNEL assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies for infertility) — Analysis of Infectious Chronic Endometritis (ALICE) (Igenomix).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Anti-CarP (anti-carbamylated proteins) panel.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antinuclear antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiovarian antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphospholipid antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidic acid antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylethanolamine antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylglycerol antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylinositol antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiphosphatidylserine antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antiprothrombin antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithrombin III (ATIII) activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithrombin III (ATIII) antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — antithyroglobulin antibodies.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — embryotoxicity assay.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Endometrial Microbiome Metagenomic Analysis (EMMA) (Igenomix).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — endometrial receptivity testing (endometrial receptivity analysis [Igenomix], endometrial receptivity array [ERA], integrin testing, beta-3 integrin test).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Factor V Leiden coagulation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Factor V Leiden mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — HLA genotyping (A, B, C, DR, DQ).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — homocysteine.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — methylenetetrahydrofolate reductase (MTHFR).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Oxidative Stress Adduct Test (OSA).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Plasminogen Activator Inhibitor-I activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Plasminogen Activator Inhibitor-I (PAI-1) antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein C activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein C antigen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein S activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — protein S antigen (free or total).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — prothrombin (Factor II) mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — uterine and endometrial receptivity testing (Endometrial function test [EFT; cyclin E and p27] and E-tegrity).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — measurement of natural killer (NK) cell activity.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — reproductive immunophenotyping.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — serum inhibin B measurement (value in assessing ovarian reserve is uncertain).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — Th1/Th2 intracellular cytokine assay (Th1/Th2 ratio).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — uBiome SmartJane screen.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN (lab studies) — vaginal microbiota.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — urinary FSH testing (serum, not urinary, FSH is the standard of care for determining menopausal status).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — seminal alpha-glucosidase, zinc, citric acid, and acid phosphatase.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — intra-prostatic antibiotic injection.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — routine use of gamete cryopreservation in lieu of embryo cryopreservation; gamete cryopreservation to circumvent reproductive aging in healthy persons; cryopreservation of immature gametes; laser-assisted necrotic blastomere removal from cryopreserved embryos.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN — sperm cryopreservation to circumvent reproductive aging in healthy men.; NOT MEDICALLY NECESSARY — ICSI in men whose abnormal sperm quality or quantity had been rectified by varicocelectomy.; NOT MEDICALLY NECESSARY — assisted hatching unless the cycle involves transfer of the embryo into the uterus. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0327 — Infertility

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This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0327 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.