Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2010 Title: FEHBP Infertility Coverage
Revision Date: 05/01/2016 Document: BI244:00
CPT Code(s): See Below
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    This policy describes Infertility coverage under the Federal Employees Health Benefit Program.

a)    If you are not enrolled in that program, please go to BI057 for information about infertility coverage.

2)    Infertility includes all services rendered on behalf of an enrollee that are intended to learn why there is a delay in conception or to increase the likelihood of conception.

3)    All services related to infertility treatment require pre-authorization.

a)    If you are receiving services from an in-network provider, that provider is responsible to obtain the pre-authorization.

b)    If you are receiving services from an out-of-network provider, you are responsible for all pre-authorizations.

4)    The Federal Employees Health Benefit Program covers  services related to the diagnosis, evaluation and treatment of infertility, including intra-vaginal insemination, but not including:

a)    In Vitro Fertilization

b)    Embryo Transfer

c)     Gamete Intrafallopian Transfer (GIFT)

d)    Zygote Intra-Fallopian Transfer (ZIFT)

e)    Intracervical Insemination

f)      Intrauterine Insemination

g)    Medications used to treat infertility

5)    If you have questions about your financial participation in the diagnosis or treatment of infertility, please see your coverage handbook.


Medical Statement

1)    The category of infertility includes all services rendered to any enrollee which are intended to ascertain the cause of failure to conceive and carry a baby to term and all services which are intended to treat any cause of failure or delay in conceiving a baby or failure to carry that baby to term.

2)    Among plans administered by QualChoice, the FEHBP program is unique in offering broad coverage for the diagnosis and treatment of infertility.

a)    For information about coverage under other programs than the FEHBP program, please see BI057.

b)    Most diagnostic and treatment services are covered (see below for the exceptions).

c)     All services related to infertility require preauthorization.

3)    The FEHBP program does not cover the following services related to infertility:

a)    In Vitro Fertilization

b)    Embryo Transfer

c)     Gamete Intrafallopian Transfer (GIFT)

d)    Zygote Intra-Fallopian Transfer (ZIFT)

e)    Intracervical Insemination

f)      Intrauterine Insemination

g)    Medications used to treat infertility

4)     If there are questions about coverage, please call Care Management.


Application to Products

This policy applies to the Federal Employees Health Benefit Program and to no other program of coverage offered or administered by QualChoice. For information on this subject related to other coverage programs, please see BI057.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.