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| Section: | Maternity |
| Number: | U-5 |
| Topic: | Assisted Fertilization |
| Effective Date: | January 31, 2011 |
| Issued Date: | January 31, 2011 |
| Date Last Reviewed: |
Indications and Limitations of Coverage
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.
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. Related services, including but not limited to lab work and ultrasound, performed in preparation for or in conjunction with assisted fertilization services should be reported with the appropriate ICD-9-CM code for artificial insemination or IVF, GIFT, ZIFT, etc. (see the "Diagnosis Codes" section) in order to distinguish them as services associated with an artificial fertilization program. Such services are non-covered when the member does not have the benefit for artificial fertilization. A participating, preferred, or network provider can bill the member for the non-covered service. 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. Report the appropriate ICD-9-CM code for artificial insemination or IVF, GIFT, ZIFT, etc. (see the "Diagnosis Codes" section) in order to distinguish them as services associated with an artificial fertilization program. Such services 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 service. When assisted fertilization is successful, payment can be made for managing the pregnancy and delivery. Refer to Medical Policy Bulletin X-26 for information on ultrasound studies for the diagnosis and treatment of infertility. Ovulation Induction Management 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 may occur laparoscopically naturally. Any resulting embryo floats into the uterus for possible implantation. 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 laparoscopically transferred into the woman's fallopian tube within 24 hours of fertilization. The zygote travels through the fallopian tube and into the uterus where natural implantation in the endometrial lining may take place. 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. The embryos naturally travel into the uterus where natural implantation in the endometrial lining may take place. |
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| 55870 | 58321 | 58322 | 58323 | 58970 | 58974 |
| 58976 | 76948 | 84702 | 89250 | 89251 | 89253 |
| 89254 | 89255 | 89257 | 89258 | 89259 | 89260 |
| 89261 | 89264 | 89268 | 89272 | 89280 | 89281 |
| 89290 | 89291 | 89335 | 89342 | 89343 | 89344 |
| 89346 | 89352 | 89353 | 89354 | 89356 | S4026 |
| S4027 | S4028 | S4030 | S4031 | S4040 | S4042 |
| 0058T | 0059T |
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Diagnosis and treatment of infertility is covered, except as shown in non-covered section (below) Non-covered: Assisted reproductive technology (ART) procedures,
Services and supplies related to ART procedures, such as sperm banking. |
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PRN References 10/2004, Reporting guidelines for ovulation induction management explained |
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| [Version 006 of U-5] |
| [Version 005 of U-5] |
| [Version 004 of U-5] |
| [Version 003 of U-5] |
| [Version 002 of U-5] |
| [Version 001 of U-5] |
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* May also be used in the diagnosis/treatment of infertility outside of an assisted fertilization program. |
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For Artificial Insemination
| V26.1 |
For IVF, GIFT, ZIFT, etc.
| V26.81 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Highmark West Virginia plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
