These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own 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.
Does not require prior approval.
Advanced ART including, but not limited to IVF, GIFT, ZIFT and ICSI are generally an exclusion in your member contract and not eligible for coverage.
- Advanced assisted reproductive technologies, including but not limited to IVF, GIFT, TET, ZIFT, ICSI, MESA and all charges associated with such procedures
- Sperm, ova or embryo acquisition retrieval or storage based on contractual exclusions
- Gestational carrier/surrogate pregnancy and all topics defined below based on contractual exclusions.
Assisted reproductive technologies (ART): a group of procedures developed to facilitate fertilization and normal delivery for infertile couples. Advanced ART include, but are not limited to IVF, GIFT, ZIFT and ICSI, which are described below.
Gamete intrafallopian tube transfer (GIFT): a procedure where medication is used to stimulate egg production. The egg is then removed via laparoscopy (surgery which inserts small instrument into small incision below naval) and immediately mixed with washed sperm. This sperm-egg mixture is then transferred into the fallopian tubes where fertilization may then take place. Gamate refers to the male or female reproductive cells the sperm and egg.
Intracytoplasmic sperm injection (ICSI): A single sperm is injected directly into the egg. This is used in cases of male infertility.
In vitro fertilization (IVF): A procedure in which an egg is removed from the woman and fertilized by a sperm cell outside the human body. The fertilized egg is allowed to divide in a protected environment for about two days and then is inserted back into the uterus of the woman who produced the egg. Also called test tube baby and test tube fertilization.
Zygote intrafallopian tube transfer (ZIFT): The egg and sperm join in the laboratory and the zygote (embryo in early development stage) is transferred into the fallopian tube.
Nonsurgical tubal embryo transfer (TET): The transfer of a zygote, or fertilized egg, into a fallopian tube two days after fertilization.
Transfer of cryopreserved embryos: A procedure where embryos frozen from a previous cycle and successfully thawed are transferred to the uterus for implantation.
Microinsemination: Laboratory technique whereby sperm are injected next to the egg cell surface to increase the likelihood of fertilization.
Assisted hatching: A microinjection procedure which chemically dissolves the embryo surface to facilitate implantation.
Donor sperm program: Use of sperm collected from a man who is not the woman recipient’s partner.
Donor egg program: Eggs removed from the ovaries of a female donor for use in an infertile patient.
Donated embryo program: Transfer of an embryo developed from a volunteer for use by an infertile recipient.
Gestational carrier: Surrogate pregnancy when another woman carries the pregnancy for an infertile couple. Often IVF is used to create the pregnancy.
MESA: Microscopic Epididymal Sperm Aspiration is performed when sperm cannot move through the male genital tract due to an uncorrectable blockage. Sperm is extracted directly from the epididymis (tube which normally carries sperm out of the body) by microsurgical techniques. This may be done when there is a lack or blockage of the tubes that normally carry sperm out, or when an attempt to reverse a vasectomy has failed to produce any sperm. It is done in conjunction with IVF and or ICSI.
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.