Coverage for assisted fertilization is determined according to individual or group customer benefits.

The procedures listed on the Table Attachment below may be reported as part of an assisted fertilization program:

NOTE:

This is not an all-inclusive list. The coverage of these procedures may vary according to group specific benefits.

 

NOTE:

The following are noncovered professional services because there is no physician service rendered. Charges for cryopreservation, storage, procurement, and thawing of specimens are generally facility charges which should be processed in accordance with the member’s benefits:

 

cryopreservation of oocytes (0059T)

cryopreservation of embryo(s) (89258)

cryopreservation of sperm (89259)

cryopreservation of reproductive ovarian tissue (0058T)

cryopreservation of reproductive testicular tissue (89335)

storage of oocyte (89346)

storage of embryo(s) (89342)

monitoring and storage of cryopreserved embryos (S4040)

storage of previously frozen embryos (S4027)

storage of sperm/semen (89343)

storage of ovarian/testicular reproductive tissue (89344)

procurement of donor sperm from sperm bank (S4026)

sperm procurement and cryopreservation services (S4030, S4031)

thawing of oocytes (89356)

thawing of cryopreserved embryo(s) (89352)

thawing of sperm/semen (89353)

thawing of reproductive tissue (89354) 

Assisted fertilization services are generally excluded from standard medical-surgical contracts, and are not eligible for reimbursement.  However, all medical, surgical, and diagnostic services performed to diagnose and treat infertility are generally covered unless the individual member’s contract contains an exclusion with regard to the diagnosis and treatment of infertility.  Once it has been established that the ultimate goal for the infertile patient is assisted fertilization (AI, IVF, GIFT, ZIFT, etc.), all subsequent related diagnostic, medical, and surgical services are considered part of the assisted fertilization program, and are non-covered when the member does not have an assisted fertilization benefit.  A participating, preferred or network provider can bill the member for the denied procedure.

When reported, assisted fertilization program management should be processed under the appropriate procedure codes for the services rendered. Assisted fertilization program management generally includes, but is not limited to, such services as a history and physical, daily visits, consultations for medication adjustment, and counseling.

When assisted fertilization is successful, payment can be made for managing the pregnancy and delivery.

Ovulation Induction Management

Ovulation induction management (cycle management) involves the medical management of the patient where medication is used to stimulate development of mature follicles within the ovaries.

Ovulation induction management may be performed as part of an assisted fertilization program or as a treatment for infertility outside of an assisted fertilization program.  This service may be reported using an appropriate evaluation and management procedure code, provided that there is patient/physician interaction and all of the components of the E&M code have been met.

Ovulation induction management performed without a face-to-face patient/physician encounter (e.g., conducted via telephone) may be considered an eligible service.  Procedure code S4042 should be used to report ovulation induction management services involving the interpretation/discussion of laboratory test results and clarification of medication dosage or instructions where there is no face-to-face contact between the physician and the patient.  Procedure code S4042 should be reported once for each cycle of ovulation induction management.  Global reimbursement will be applied for each cycle of non face-to-face ovulation induction management (S4042) in accordance with the individual member's contract. 

Additionally, other services performed within the ovulation induction management process (e.g. laboratory tests, ultrasound, etc.) should be reported individually with the appropriate procedure code and will be paid in accordance with the individual member’s contract.

When performed for treatment of infertility, global payment for non face-to-face ovulation induction management (S4042) is limited to twelve times (cycles) within a 12 month period. 

Description

Infertility is the medically documented diminished ability to conceive or induce conception. A couple is considered infertile if pregnancy does not occur over a one-year period of normal coital activity between a male and female partner without contraceptives. The cause of infertility can be a female or male factor, or a combination of both.

Ovulation induction involves the use of medication to stimulate development of mature follicles within the ovaries.

Assisted fertilization techniques enhance sperm-egg interaction. Management of the infertile couple with assisted fertilization is generally limited to those couples who do not respond to infertility treatments (e.g., tuboplasty for the female, microsurgical reconstruction for the male).

Assisted fertilization techniques include the following. (This is not an all-inclusive list.)

ARTIFICIAL INSEMINATION (AI): Frozen sperm is transferred by catheter either directly into the uterus, bypassing the cervix and upper vagina (intrauterine insemination), or directly into the cervix (intracervical insemination). Artificial insemination may be performed in the course of a natural cycle or an ovulation induction cycle (e.g., Clomid, Pergonal).

IN VITRO FERTILIZATION (IVF): Eggs and sperm are combined in a laboratory dish where fertilization occurs. Two days after the retrieval, the embryo is transferred into the woman's uterus.

BLASTOCYST TRANSFER: The blastocyst transfer procedure is virtually identical to IVF, with one key exception, the embryo is allowed to develop outside the womb for four or five days instead of two or three. The extra time allows the embryo to become a multicelled structure called a blastocyst. The blastocyst is then implanted in the patient's uterus.

GAMETE INTRAFALLOPIAN TRANSFER (GIFT): Eggs and sperm are mixed in a laboratory dish. The unfertilized combination is deposited directly into the woman's fallopian tube where fertilization occurs naturally. Any resulting embryo floats into the uterus.

ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT): Eggs and sperm are combined in a laboratory dish where fertilization occurs. Before the zygote, or pre-embryo has divided, it is transferred into the woman's fallopian tube.

TUBAL EMBRYO TRANSFER (TET): Tubal embryo transfer is essentially synonymous with zygote intrafallopian transfer (ZIFT). In this procedure, embryos are placed into the fallopian tube by laparoscopy or transuterine, transcervical tubal cannulation.

PERITONEAL OVUM SPERM TRANSFER: Oocytes recovered by laparoscopic or transvaginal oocyte retrieval are mixed with a suspension of sperm and injected across the vaginal mucosa into the posterior cul de sac.

Pergonal therapy, or Pergonal in conjunction with Clomid or other covered fertility drugs, is covered for the diagnosis of infertility, regardless of when they are prescribed.

Ultrasounds and related tests performed to monitor the effectiveness of fertility drug therapy are also covered. However, any tests that are exclusively rendered to monitor the effectiveness of noncovered fertilization procedures are excluded from coverage.

PRN References

10/2004, Reporting guidelines for ovulation induction management explained

* May also be used in the diagnosis/treatment of infertility outside of an assisted fertilization program.