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HealthPartners

Coverage criteria policies

Infertility diagnosis and treatment

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

Prior authorization is not required for diagnosis or treatment of infertility.

Testing for genetic causes of infertility is outside the scope of this policy. Please see the related content at right for the link to the Genetic testing: carrier screening, prenatal screening, prenatal diagnosis, and infertility evaluation coverage policy.

Please see the Artificial insemination (AI) or intrauterine insemination (IUI) coverage policy for information about those procedures.

Coverage

Diagnostic infertility evaluation and treatment 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 this service.

Coverage is limited to HealthPartners members.

Indications that are covered

Infertility evaluation – female

Initial diagnostic evaluation of infertility is generally covered for women with involuntary inability to conceive after one year of appropriate, timed unprotected intercourse or insemination (including artificial insemination and intrauterine insemination). Evaluation may be appropriate for women not meeting the one-year condition in the following circumstances: age 35 or greater, known ovarian dysfunction, history of Pelvic Inflammatory Disease (PID), known endometriosis.

A woman should seek a diagnostic evaluation for infertility immediately if she has a medical history significant for oligomenorrhea, amenorrhea, advanced stage endometriosis (see definitions below), or any other conditions that could limit fertility.

The initial basic infertility work up is generally completed over 2-3 menstrual cycles in a 3-6 month period. The objective should be prompt work up to rule out obvious causes.

Routine laparoscopy should not be performed in the evaluation of the infertile female but may be warranted when there is a strong suspicion of advanced stage endometriosis, tubal occlusive disease, or peritoneal factors.

Women who are not known to have comorbidities (such as Pelvic Inflammatory Disease (PID), previous ectopic pregnancy or endometriosis) should be offered hysterosalpingography (HSG) to screen for tubal occlusion because this is a reliable test for ruling out tubal occlusion, and it is less invasive and makes more efficient use of resources than laparoscopy.

Infertility evaluation – male

Diagnostic evaluation of infertility in the male is generally covered when recommended as appropriate and ordered by the member’s physician. The evaluation must be within the limits of the member's Contract.

Infertility treatment – female and male

Treatment of diagnosed infertility is generally covered when recommended as appropriate by the member’s physician and within the limits of the member's Contract.

Indications that are not covered

  1. Diagnostic evaluation for infertility is not covered when the member has had an elective sterilization.
  2. Surgery or any treatment for the reversal of elective sterilization is not covered.
  3. Treatment involving investigative or excluded procedures.
  4. Any treatment or medications used for assisting with advanced artificial reproductive technologies (AART) such as in-vitro fertilization (IVF), gamete intrafallopian tube transfer (GIFT), zygote intrafallopian tube transfer (ZIFT), and intracytoplasmic sperm injection (ICSI). (Example: Pergonal would be covered for use with 6 cycles of artificial insemination (AI) or intrauterine insemination (IUI), which are covered. It would not be covered with IVF, which is generally not covered).
  5. Ova or sperm acquisition and/or storage are not covered per contractual exclusion.

Definitions

Amenorrhea is the medical term for the lack of a menstrual period. Amenorrhea is not a disease, but it can be a symptom of another condition. Primary amenorrhea occurs when a girl has not had her first period by age 16. Secondary amenorrhea describes women who experience an absence of more than three menstrual cycles after having regular periods.

Cycle - For the purpose of this policy and benefit coverage, a cycle refers to a menstrual cycle, generally 28-32 days. However, in the infertile patient a cycle may run from 30 to 50 days with no identifiable pattern.

Drugs - A group of medications used to stimulate ovulation. Examples include but are not limited to the following:

  1. Oral ovulatory stimulation – Clomiphene
  2. Superovulatory drugs - injectable medications: A list of covered products is available at the HealthPartners Drug Formulary.

Endometriosis – a condition in which uterine tissue begins to grow beyond the uterus, affecting other organs throughout the pelvic region and sometimes beyond. Symptoms of endometriosis include pelvic pain - which is often worse during a woman’s period - as well as inability to get pregnant and sometimes the development of ovarian cysts and scar tissue. Women who have endometriosis may also have irregular periods that include abnormally heavy bleeding or bleeding between periods.

Hysterosalpingography (HSG) – also called uterosalpingography, is an x-ray examination of a woman's uterus and fallopian tubes that uses a special form of x-ray called fluoroscopy and a contrast material.

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).

Infertility diagnostic evaluation is the method used to establish a logical basis for initial treatment such as evaluation of ovarian function, hormonal function, reproductive organ function, and ovulation function.

Laparoscopy – a surgical procedure in which a fiber-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to permit a surgical procedure.

Oligomenorrhea – infrequent menstrual periods (e.g., periods that occur more than 35 days apart).

Ova - eggs

Ovulation - The discharge of the egg from the ovary.

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 College of Obstetricians and Gynecologists. (2014). Female age-related fertility decline. Committee opinion no. 589. Obstetrics & Gynecology, 123, 719–21.
  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
  3. American Society for Reproductive Medicine. (2015). Diagnostic evaluation of the infertile female: a committee opinion. Fertility and Sterility, 103(6), e44-e50. http://dx.doi.org/10.1016/j.fertnstert.2015.03.019
  4. National Institute for Health and Care Excellence. (2013). Fertility problems: assessment and treatment. NICE guideline (CG156).