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HealthPartners

Coverage criteria policies

Artificial insemination (AI) or intrauterine insemination (IUI)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Artificial insemination and intrauterine insemination do not require prior authorization.

Coverage

Artificial insemination (AI) and intrauterine insemination (IUI) are generally covered when the member has a specific infertility benefit and per the indications listed below. Due to variations in member contracts, please check with Member Services for information regarding specific coverage for these services.

Indications that are covered

  1. The member has a diagnosis of infertility. Examples include:
    1. A female member with a diagnosis of infertility.
    2. Couples where both the male and female are members and one or both have a diagnosis of infertility.
    3. Diagnoses that include male factor infertility, cervical factor infertility and unexplained infertility.
  2. Six cycles (see definition of cycle below) per confirmed pregnancy. The benefits renew after documentation of pregnancy.
  3. Supraovulatory drugs may be given alone or in combination with another supraovulatory drug during AI or IUI treatment. Six cycles of drugs are covered with the covered six cycles of AI or IUI per pregnancy unless the member has already received six cycles of supraovulatory drugs prior to starting AI or IUI.

Indications that are not covered

  1. When the person with the diagnosis or receiving treatment is not a covered member. Examples include:
    1. The male partner is the member and the female partner has an infertility diagnosis. AI or IUI would not be covered for this couple because the procedure would not be performed on the covered member (the male).
    2. The male partner is the member and has an infertility diagnosis. AI or IUI would not be covered for this couple because the procedure would not be performed on the covered member (the male).
  2. The following, which are stated in the contract under Exclusions:
    1. When artificial insemination is requested due to previous elected sterilization.
    2. Charges for more than six cycles of AI or IUI per pregnancy.
    3. Sperm or ova retrieval and sperm, ova or embryo storage.
    4. Supraovulatory medication beyond six cycles per pregnancy. Some courses of treatment for Infertility include supraovulatory medications before AI or IUI are performed. More than six cycles of supraovulatory medications per cycle are not covered, so occasionally the AI & IUI would be covered but the medications would not be covered.

Note: The benefits cease the day after the 6th cycle.

Definitions

Artificial insemination (AI) is placing sperm into a woman's vagina for the purpose of conception.

Cycle: For the purpose of this policy and benefit coverage, a cycle refers to a menstrual cycle, generally 28-32 days. There may be two AIs or IUIs done during one menstrual cycle. For the purpose of benefit coverage, these two AIs or IUIs would be considered one cycle.

Infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35 years. Disease is defined as “any deviation from or interruption of the normal structure or function of any part, organ or system of the body as manifested by characteristic symptoms and signs; the etiology, pathology and prognosis may be known or unknown” (American Society for Reproductive Medicine, 2013).

Intra-uterine insemination (IUI) is placing sperm into a woman's uterus for the purpose of conception.

Ova: Eggs

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

58321

Artificial insemination; intra-cervical

58322

Artificial insemination; intra-uterine

58323

Sperm washing for artificial insemination

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

S4035

Stimulated intrauterine insemination (IUI), case rate

S4042

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

S4042

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

ICD-10-PCS codes

Codes

Description

3E0P3LZ

Introduction of Sperm into Female Reproductive, Percutaneous Approach

3E0P7LZ

Introduction of Sperm into Female Reproductive, Via Natural or Artificial Opening

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Society for Reproductive Medicine. (2006). Effectiveness and treatment for unexplained infertility. Fertility and Sterility, 86(4), S111-S114. doi:10.1016/j.fertnstert.2006.07.1475
  2. American Society for Reproductive Medicine. (2013). Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertility and Sterility, 99(1), 63. http://dx.doi.org/10.1016/j.fertnstert.2012.09.023

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Policy activity

  • 01/01/1994 - Date of origin
  • 01/01/2018 - Effective date
Review date
  • 05/2017
Revision date
  • 05/23/2017

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