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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-56000-24

Original Effective Date: 11/15/00

Reviewed: 08/25/16

Revised: 09/15/16

Subject: Infertility

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Infertility diagnosis, treatment, assisted reproductive technologies (e.g., IVF, ZIFT, GIFT) and artificial and intrauterine insemination (AI) vary by member’s benefits.

Infertility is defined as inability to conceive a child despite trying for one year, or the inability of the woman to carry a pregnancy that results in live birth.

Some causes of infertility include the following:

In some cases, no specific cause of infertility is detected despite an extensive and complete evaluation.

Assisted reproductive technologies (ART) refer to several interventions designed to establish a viable pregnancy for individuals who have been diagnosed with infertility; due either to female factors (e.g., pelvic adhesions, ovarian dysfunction, endometriosis, prior tubal ligation), male factors (e.g., abnormalities in sperm; production, function, transport, or prior vasectomy), a combination of both male and female factors, or unknown causes.

Assisted reproductive technologies include: in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), donor oocytes, and cryopreserved embryo transfers (CET). ART incorporates some type of in vitro fertilization (IVF) procedure in which oocytes harvested from the female are inseminated in vitro with sperm harvested from the male. Following the fertilization procedure, the zygote is cultured and ultimately transferred back into the female’s uterus or fallopian tubes (zygote intrafallopian transfer [ZIFT]). In some instances, the oocyte and sperm are collected, but no in vitro fertilization takes place, and the gametes are reintroduced into the fallopian tubes (gamete intrafallopian transfer [GIFT]).

Artificial Insemination (AI) encompasses a variety of procedures (e.g., intracervical, intrauterine (IUI)) involving placement of whole semen or processed sperm into the female reproductive tract, which permits sperm-oocyte interaction in the absence of intercourse. AI uses processed sperm from the male partner or a donor.

Relatively new ART techniques include: intracytoplasmic sperm injection (ICSI), assisted hatching, co-culture of embryos, and cryopreservation of reproductive tissue (e.g., ovarian, oocytes, testicular).

Intracytoplasmic Sperm Injection (ICSI) is performed in cases of male factor infertility when either insufficient numbers of sperm, abnormal morphology, or poor motility preclude unassisted in vitro fertilization.

Assisted Hatching one key component of a successful attempt at in vitro fertilization is implantation of the embryo in the uterus. It is hypothesized that during the in vitro component of the IVF, the zona pellucid becomes hardened, thus impairing the hatching process. Alternatively, some embryos may have some inherent inability to induce thinning of the zona pellucida before hatching. Mechanical disruption of the zona pellucida (e.g., assisted hatching) has been proposed as a mechanism to improve implantation rates. There is no evidence that assisted hatching should be routinely performed as part of IVF procedures.

Embryo Co-Culture a variety of co-culture techniques have been investigated, involving the use of feeder cell layers derived from a range of tissues, including the use of human reproductive tissues (e.g., oviducts) to non-human cells (e.g., fetal bovine uterine or oviduct cells) to established cell lines (e.g., Vero cells or bovine kidney cells). No standardized method of co-culture has emerged and no controlled trials have evaluated an improved implantation or pregnancy rate associated with co-culture.

Cryopreservation of Ovarian tissue with subsequent auto or heterotopic transplant has been investigated as a technique to sustain the reproductive function of women or children who are faced with sterilizing procedures, such as chemotherapy, radiation therapy, surgery, or due to malignant diseases. Cryopreservation of ovarian tissue techniques is not standardized, and the overall success of the procedure cannot be determined from individual case reports.

Cryopreservation of Oocytes is less commonly performed in the setting of malignancy due to the time constraints inherent in ovarian stimulation. Oocyte cryopreservation has been primarily investigated as an alternative to embryo cryopreservation due to ethical or religious reasons. The technique for cryopreservation and thawing of oocytes has not been established and there is a lack of long-term experience with this technique.

Cryopreservation of Testicular Tissue Testicular sperm extraction (TESE) refers to the collection of sperm from testicular tissue in men with azoospermia. TESE may be performed at the time of a diagnostic biopsy, or performed as a subsequent procedure, specifically for the collection of spermatozoa. The spermatozoa may be isolated immediately and a portion used for an ICSI procedure at the time of oocyte retrieval from the partner, with the remainder cryopreserved. Alternatively, the entire tissue sample can be cryopreserved with portion thawed and sperm isolation performed at subsequent ICSI cycles. This technique appears to be a well-established component of the overall ICSI procedure; cryopreservation of either the isolated sperm of the tissue sample eliminates the need for multiple biopsies to obtain fresh tissue in the event of a failed initial ICSI cycle.

Cryopreservation of Testicular Tissue in prepubertal boys may be considered in those undergoing chemotherapy for cancer. The goal of cryopreservation in prepubertal boys undergoing chemotherapy is maintenance of fertility potential by auto-transplanting the testicular tissue when chemotherapy has been completed. While cryopreservation of testicular tissue in prepubertal boys have been explored in animals, there are inadequate human studies.

Blastocyst Transfer refers to the extended culture of oocytes/embryos, i.e., for greater than 4 days. The development of commercially available sequential media designed to reproduce the changes in nutrient requirements as the embryo develops has permitted the extended culture of embryos to the blastocyst stage, at which point the embryos are transferred. The rationale behind blastocyst transfer is that embryos progressing to the blastocyst stage have a much greater chance of implanting successfully in the uterus and resulting in an ongoing pregnancy. Blastocyst culture allows one to select the best quality embryo with the highest implantation potential.

POSITION STATEMENT:

NOTE: Coverage for infertility is subject to the member’s benefit terms, limitations and maximums. Refer to contract language regarding infertility.

If the benefit for coverage for infertility treatment is available and there is documentation of infertility for at least one year’s duration, the following indications meet the definition of medical necessity:

For fertility drug coverage, refer to member’s contract benefits.

For diagnostic testing coverage for infertility, refer to member’s contract benefits.

NOTE: Family balancing is not eligible for coverage. Family balancing is a measured approach to a non-medically indicated use of preconception gender selection. Family balancing provides couples having at least one child the opportunity to use MicroSort to increase the chance of having another child of the less represented sex in the family.

The following assisted reproductive techniques meet the definition of medically necessity:

The following assisted reproductive techniques are considered experimental or investigational.

Assisted hatching is considered experimental or investigational, as there is insufficient clinical evidence to support the use of assisted hatching.

Embryo co-culture of oocyte(s)/embryos is considered experimental or investigational as there is insufficient clinical evidence to support the use of embryo co-culture of oocyte/embryo to improve the culture media for embryos, in order for a greater proportion of embryos to remain viable until implantation. Embryo co-culture techniques are not standardized embryos and a higher clinical pregnancy rate.

Cryopreservation of ovarian tissue, including storage and thawing of ovarian tissue, is considered experimental or investigational, as there is insufficient clinical evidence to support the use of cryopreservation of ovarian tissue, including storage and thawing of ovarian tissue. Cryopreservation of ovarian tissue is not standardized.

Cryopreservation of ovarian tissue with subsequent auto-or heterotopic transplant has been investigated as a technique to sustain the reproductive function of women or children who are faced with sterilizing procedures, such as chemotherapy, radiation therapy, or surgery (frequently due to malignant diseases).

Cryopreservation of oocyte(s), including storage and thawing of oocytes, is considered experimental or investigational, as there is insufficient clinical evidence to support the use of cryopreservation of oocytes.

Cryopreservation of testicular tissue, including storage and thawing of testicular tissue in prepubertal boys is considered experimental or investigational, as there is insufficient clinical evidence to support the use of cryopreservation of testicular tissue in prepubertal boys. Cryopreservation of testicular tissue in prepubertal boys has been explored in animals; there are inadequate human studies for cryopreservation of testicular tissue in prepubertal boys.

(NOTE: Cryopreservation of testicular tissue meets the definition of medical necessity in adult men with azoospermia as part of an intracytoplasmic sperm injection (ICSI) procedure.)

BILLING/CODING INFORMATION:

The following are some of the codes that may be used to report services that may be associated with infertility and diagnostic testing for infertility.

NOTE: Coverage for infertility is subject to the member’s benefit terms, limitations and maximums. Refer to contract language regarding infertility.

NOTE: Coverage for diagnostic testing for infertility is subject to the member’s benefit terms, limitations and maximums. Refer to contract language regarding diagnostic testing for infertility.

CPT Coding:

10021

Fine needle aspiration; without imaging guidance

10022

Fine needle aspiration; with imaging guidance

54500

Biopsy of the testis, needle

54800

Biopsy of epididymis, needle

55400

Vasovasostomy, vas vasorrhaphy

55870

Electroejaculation (may be used in patients who are unable to produce a normal ejaculate due to spinal cord or other nervous system disorder i.e., diabetic neuropathy)

58321

Artificial insemination; intra-cervical

58322

Artificial insemination; intra-uterine

58323

Sperm washing for artificial insemination

58345

Transcervical introduction of fallopian tube catheter for diagnosis AND/OR re-establishing patency (any method), with or without hysterosalpingography

58970

Follicle puncture for oocyte retrieval, any method

58974

Embryo transfer, intrauterine

58976

Gamete, zygote or embryo intrafallopian transfer, any method

89250

Culture of oocyte(s)/embryo(s), less than 4 days

89251

Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos (investigational)

89253

Assisted embryo hatching, micro techniques (any method)

89254

Oocyte identification from follicular fluid

89255

Preparation of embryo for transfer (any method)

89257

Sperm identification from aspirate (other than seminal fluid)

89258

Cryopreservation; embryo(s).

89259

Cryopreservation sperm.

89260

Sperm isolation; simple prep (e. g., sperm wash and swim-up) for insemination or diagnosis with semen analysis

89261

Sperm isolation; complex prep (e. g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis.

89264

Sperm identification from testis tissue, fresh or cryopreserved

89268

Insemination of oocytes

89272

Extended culture oocyte(s)/embryo(s), 4 – 7 days

89280

Assisted oocyte fertilization, micro technique; less than or equal to 10 oocytes

89281

Assisted oocyte fertilization, micro technique; greater than 10 oocytes

89290

Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos

89291

Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); greater than 5 embryos (non-covered)

89300

Semen analysis; presence AND/OR motility of sperm including Huhner test (post coital)

89310

Semen analysis; motility and count (not including Huhner test)

89320

Semen analysis; volume, count, motility, and differential

89321

Semen analysis; sperm presence and motility of sperm, if performed

89322

Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger)

89325

Sperm antibodies

89329

Sperm evaluation; hamster penetration test

89330

Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test

89331

Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)

89335

Cryopreservation, reproductive tissue, testicular

89337

Cryopreservation, mature oocyte(s) (investigational)

89342

Storage, (per year); embryo(s)

89343

Storage, (per year); sperm/semen

89344

Storage, (per year); reproductive tissue, testicular/ovarian (investigational)

89346

Storage, (per year); oocyte (investigational)

89352

Thawing of cryopreserved; embryo(s)

89353

Thawing of cryopreserved; sperm/semen, each aliquot

89354

Thawing of cryopreserved; reproductive tissue, testicular/ovarian (investigational)

89356

Thawing of cryopreserved; oocytes, each aliquot (investigational)

0058T

Cryopreservation; reproductive tissue, ovarian (investigational)

0357T

Cryopreservation; immature oocyte(s) (investigational)

HCPCS Coding:

S3655

Antisperm antibodies test (immunobead)

S4011

In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development

S4013

Complete cycle, gamete intrafallopian transfer (GIFT), case rate

S4014

Complete cycle, zygote intrafallopian transfer (ZIFT), case rate

S4015

Complete in vitro fertilization cycle, not other wise specified case rate

S4016

Frozen in vitro fertilization cycle, case rate

S4017

Incomplete cycle, treatment canceled prior to stimulation, case rate

S4018

Frozen embryo transfer procedure canceled before transfer, case rate

S4020

In vitro fertilization procedure cancelled before aspiration, case rate

S4021

In vitro fertilization procedure cancelled after aspiration, case rate

S4022

Assisted oocyte fertilization, case rate

S4023

Donor egg cycle, incomplete, case rate

S4025

Donor services for in vitro fertilization (sperm or embryo), case rate

S4026

Procurement of donor sperm from sperm bank

S4027

Storage of previously frozen embryos

S4028

Microsurgical epididymal sperm aspiration (MESA)

S4030

Sperm procurement and cryopreservation services; initial visit

S4031

Sperm procurement and cryopreservation services; subsequent visit

S4035

Stimulated intrauterine insemination (IUI), case rate

S4037

Cryopreserved embryo transfer, case rate

S4040

Monitoring and storage of cryopreserved embryos, per 30 days

S4042

Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management of the patient), per cycle

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT and BILLING/CODING INFORMATION.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services, (DL33777) located at fcso.com.

DEFINITIONS:

ART: Assisted Reproductive Technologies.

Artificial insemination (AI): placement of semen into the uterus with a syringe.

Azoospermia: lack of live spermatozoa in the semen.

Cryopreservation: special freezing process.

Cryopreserved embryo transfer (CET): once embryos have been fertilized in the lab, they are frozen (reserved) and later transferred to the uterus.

Direct intra-peritoneal insemination (DIPI): process-attempting fertilization inside the body by placing a needle into the abdomen.

Donor egg (DE): an egg donated from a woman other than the patient.

Electroejaculation: this procedure assists men who are unable to ejaculate; electricity is sent through the pelvic area to assist in ejaculation.

Embryo: an egg fertilized with sperm.

Fallopian tubes: tubes connecting the uterus to the area around the ovaries. Eggs travel through the tubes to reach the uterus.

Fertilization: egg penetrated by sperm to form an embryo.

Gamete intrafallopian transfer (GIFT): a form of IVF; eggs are harvested from the ovary, loaded into a tube with sperm, and immediately placed into the fallopian tube with special scope for fertilization inside the body.

Gamete: a mature male or female reproductive cell (sperm or ovum).

Hysterosalpingography: x-ray test where dye is injected into the uterus and fallopian tubes, to see their structure.

In vitro fertilization (IVF): the egg is fertilized with sperm in a dish in a laboratory, rather than inside a woman’s body. The resulting embryo is placed into the uterus later. One “cycle” of IVF includes using medicines to stimulate the ovaries to ovulate, “harvesting” the eggs with an instrument, attempting to fertilize the eggs with sperm in the lab, and placing any embryos into the uterus.

Intra-cytoplasmic sperm injection (ICSI sperm): ICSI can be used to treat male infertility disorders, such as low sperm count, low sperm motility, abnormally shaped sperm, or azoospermia (complete absence of sperm in the man’s ejaculate). In a dish in the lab, sperm is injected into the egg to fertilize it, rather than letting it penetrate the egg naturally. Embryos are transferred to the uterus.

Intrauterine: inside the uterus.

IUI: intrauterine insemination. A procedure, which involves placing sperm inside a women’s uterus to facilitate fertilization.

Laparoscopy: a small cut is made in the skin, and a scope with a light on the end is placed inside the abdomen.

Microfertilization (egg drilling or tweaking): this technique creates a cut in the egg, so that sperm can get in more easily. A “subzonal microinjection” places the sperm between the egg and it’s outer covering, and a “partial zonal dissection” cuts the egg before it is incubated with sperm. In either case, embryos are transferred from the lab dish into the uterus.

Microsurgical epididymal sperm aspiration (MESA): in men who were born without a vas deferens, there is no way for sperm to reach the penis. This procedure places a needle into the testicle area to aspirate sperm for fertilization.

Natural oocyte retrieval (NORIVF): harvesting eggs from the ovary, when the egg has ovulated naturally.

Obstruction: blockage.

Oocyte: egg.

Ovulation: the monthly process of eggs released from the ovaries.

Sperm penetration assay: lab test designed to check the ability of sperm to enter eggs. Other terms for this test are the heterologous ovum penetration test, and hamster ovum test. A hamster egg (ovum) is used as the target, and sperm are placed in a dish with these eggs for several hours. The number of eggs with sperm penetration is counted, and the semen sample is rated as “fertile” or “non-fertile”.

Spermatozoa: a mature male germ cell, the specific output of the testes. It is the generative element of the semen, which serves to fertilize the ovum, and contains the genetic information to be transmitted to the zygote by the male.

Vas deferens: tube connecting the testicles to the penis. Sperm travels along this path during ejaculation.

Voluntary sterilization: choosing to undergo a process that makes a person unable to reproduce (e.g., tubal ligation (tubes tied) in women or vasectomy in males.

Zygote intra-fallopian transfer (ZIFT): a form of IVF. Eggs are harvested and fertilized in a dish in the laboratory. The fertilized egg is placed inside the fallopian tube.

Zygote: a fertilized egg that has not yet divided.

RELATED GUIDELINES:

None applicable.

OTHER:

Coverage for office visits, and infertility diagnostic services (e.g., diagnostic procedures to determine the cause of infertility (diagnosis), and laboratory procedures) are covered services if the member has a benefit to cover these services.

Other names used to report infertility:

REFERENCES:

  1. American Society for Reproductive Medicine, Report on Management of Obstructive Azoospermia, 2006.
  2. American Urological Association (AUA), Inc.-Infertility Report on Evaluation of the Azoospermic Male (An AUA Best Practice Policy and American Society of Reproductive Medicine (ASRM) Practice committee Report), 2001.
  3. Bahadur G, Chatterjee R, Ralph D. Testicular Tissue Cryopreservation in Boys. Ethical and Legal Issues: Case Report. Human Reproduction 2000; 15: 14-16-20 20
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual 4.02.04 Assisted Reproductive Technologies, 04/15.
  5. D’Angelo A, Amso N, Embryo Freezing for Preventing Ovarian Hyperstimulation Syndrome, 02/27/02.
  6. Donnez J, Dolmans MM, Dennylle D et al. Live birth After Orthotopic Transplantation of Cryopreserved Ovarian Tissue. Lancet 2004; 364(9443): 1405-1410.
  7. First Coast Service Options, Inc. Noncovered Services LCD DL33777, 05/06/16.
  8. Goodwin PJ, Oktay KH, Lobo RA. Options for Preservation of Fertility in Women. New England Journal of Medicine 2005; 1418-1420 (Correspondence).
  9. Lee SJ, Schover LR, Patridge AH. American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients. Journal of Clinical Oncology 2006; 24(18): 2917-1931.
  10. Lobo RA. Current Concepts: Potential Options for Preservation of Fertility in Women. New England Journal of Medicine 2005; 64-72.
  11. Medicare Benefit Policy Manual Chapter 15-Covered Medical and Other Health Services-20.1 Physician Expense for Surgery, Childbirth and Treatment for Infertility, 06/18/12.
  12. Meirow D, Levron J, Eldar-Geva T et al. Pregnancy After Transplantation of Cryopreserved Ovarian Tissue in a Patient with Ovarian Failure After Chemotherapy. New England Journal of Medicine 2005; 318-321 (Correspondence).
  13. Myers ER, McCrory DC, Mills AA, Price TM, Swamy GK, Tantibhedhyangkul J, Wu JM, Matchar DB. Effectiveness of Assisted Reproductive Technology. Evidence Report/Technology Assessment No. 167 (Prepared by the Duke University Evidence-based Practice Center under Contract No. 290-02-0025.) AHRQ Publication No. 08-E012. Rockville, MD: Agency for Healthcare Research and Quality. May 2008.
  14. Oatway C, Gunby J Daya S. Day Three Versus Day Two Embryo Transfer Following In Vitro Fertilization or Intracytoplasmic Sperm Injection. Cochrane Database of Systematic Reviews 2004, Issue 2.
  15. Oktay K, Buyuk E, Veeck L et al. Embryo Development After Heterotopic Transplantation of Cryopreserved Ovarian Tissue. Lancet 2004; 363: 837-840.
  16. Palermo G, Joris H, Devroey P. Pregnancies After Intracytoplasmic Injection of Single Spermatozoon Into an Oocyte. The Lancet 1992; 340: 17-18.
  17. Pandian Z, Bhattacharya S, Vale L, Templeton A. In Vitro Fertilization for Unexplained Subfertility. Cochrane Database of Systematic Reviews 2005, Issue 2.
  18. Porcu E, Fabbri R, Damiano G et al. Clinical Experience and Applications of Oocyte Cryopreservation. Molecular and Cellular Endocrinology 2000; 169: 33-37.
  19. Seif MMW, Edi-Osagie ECO, Farquhar C, Hooper L, Blake D, McGinlay P. Assisted Hatching on Assisted Conception (IVF & ICSI). Cochrane Database of Systematic Reviews 2006, Issue 1.
  20. The Ethics committee of the American Society for Reproductive Medicine-Fertility Preservation and Reproduction in Cancer Patients. Fertility and Sterility 2005; 83(6): 1622-1628.
  21. The National Women’s Health Information Center U.S. Department of Health & Human Services-Infertility, 05/06.
  22. The Practice Committee of the American Society for Reproductive Medicine. Blastocyst culture and transfer in clinical-assisted reproduction. Fertility and Sterility 2008; 90:S174-7.
  23. The Practice Committee of the American Society for Reproductive Medicine. Intracytoplasmic sperm injection (ICSI). Fertility and Sterility 2008; 90: S187.
  24. The Practice Committee of the American Society of Reproductive Medicine. The role of assisted hatching in in vitro fertilization: a review of the literature. a committee opinion. Fertility and Sterility 2008; 90: S196-S198.
  25. The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology. Ovarian tissue and oocyte cryopreservation. Fertility and Sterility 2008; 90: S241-S246.
  26. Toledo AA, Wright G, Jones AE et al. Blastocyst Transfer: A Useful Tool for Reduction of High-Order Multiple Gestations in a Human Assisted Reproduction Program. American Journal of Obstetrics and Gynecology 2000; 183(2): 377-382.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/25/16.

GUIDELINE UPDATE INFORMATION:

11/15/00

Medical Coverage Guideline Revised.

01/01/02

Annual HCPCS coding update.

04/01/02

HCPCS changes.

08/15/02

Added CPT codes (89254, 89320, 89321, 89325, 89329, 89330).

01/01/03

Annual review and annual HCPCS coding update.

01/01/04

Annual HCPCS coding update: revise descriptors for the following: 89250, 89251, and 89258. Deleted the following: 89252 and 89256. Added the following: 89268, 89272, 89280, 89281, 89290, 89291, 89335, 89342, 89343, 89344, 89346, 89352, 89353, 89354, and 89396. Changed 89251 from non-covered to investigational (per BCBSA medical policy). Added 0058T and 0059T (considered investigational). Revised program exception for Medicare & More.

12/15/04

Added code 58323 and descriptor under billing/coding information-in vitro laboratory procedures. Deleted code 89523 and replace with 89253. Deleted covered codes for Medicare & More under program exceptions (Medicare Policy retired). Added code 89264 (non-covered) for Medicare & More under program exceptions. Deleted coverage statement for State group and Tropicana & Fowler White.

01/01/05

Annual HCPCS coding update: revised code 89346 descriptor. Added S4042.

05/15/05

Deleted ICD-9 diagnoses that support medical necessity.

09/15/05

Added S4018.

10/15/06

Updated DESCRIPTION section to include information regarding: intracytoplasmic sperm injection (ICSI), assisted hatching, embryo co-culture, cryopreservation of ovarian and testicular tissue and oocytes. Added coverage statement (investigational) regarding “storage and thawing” of ovarian tissue and oocytes and cryopreservation of testicular tissue to the WHEN SERVICES ARE NOT COVERED section. Revised CPT BILLING/CODING INFORMATION section. Deleted code 89399 (invalid code) and 55899 (unlisted procedure, male genital system). Added code 89335 to list of procedures not covered by Medicare. Added azoospermia and spermatozoa to the DEFINITIONS section. Updated references.

01/01/07

Annual HCPCS coding update: deleted S4036.

08/15/07

Annual review, coverage statements maintained, guideline reformatted, references updated.

01/01/08

Annual HCPCS coding update: revised 89320 and 89321 descriptor. Added 89322 and 89331.

01/01/09

Annual HCPCS coding update: deleted 0058T and 0059T. Updated references.

12/15/09

Annual review; no change in position statement. Updated references.

01/01/11

Annual HCPCS coding update; added 0058T and 0059T.

12/15/11

Annual review; revised description, member’s benefit statement, added information regarding blastocyst transfer to description, updated position statement (added assisting hatching and blastocyst transfer) and updated billing/coding and references.

12/15/12

Annual review; added cryopreservation of testicular tissue in adult men with azoospermia as part of an intracytoplasmic sperm injection procedure, intracytoplasmic sperm injection, blastocyst transfer and updated references.

05/11/14

Revision: Program Exceptions section updated.

07/01/14

Quarterly HCPCS update; added 0357T.

01/01/15

Annual HCPCS code update. Deleted 0059T. Added 89337.

09/15/16

Revision: Updated description section. Added statement for diagnostic testing for infertility to position statement section. Added note for infertility and diagnostic testing for infertility to the billing/coding information section. Added “for male factor infertility” to intracytoplasmic sperm injection. Added “including storage and thawing” to cryopreservation of testicular tissue experimental or investigational statement. Updated references.

Date Printed: August 18, 2017: 07:54 PM