Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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: 07/23/2004 Title: Infertility Diagnosis & Treatment
Revision Date: 04/01/2016 Document: BI057:00
CPT Code(s): 58321-58323, 58340, 58345, 58350, 58559, 58560, 58565, 58660, 58662, 58672, 58673, 58679, 58740, 58750, 58752, 58760, 58770, 58970, 58974, 58976, 58999, 59866, 74740, 76831, 82670, 83001, 83002, 89250, 89251, 89253-89255, 89257-89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89300, 89310, 89320, 89321, 89325, 89329, 89330, 89335, 89342-89344, 89346, 89352-89354, 89356, A4264, J3355, S0122, S0126, S0128, S4011, S4013-S4018, S4020-S4023, S4025-S4028, S4030, S4031, S4035, S4037, S4040
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)    Medical plans administered by QualChoice generally cover a limited diagnostic work-up for infertility, which is designed to screen for basic problems that might cause infertility.  This benefit is limited to a maximum of one each of the following tests per lifetime for infertility diagnosis:

a)    Semen analysis

b)    Pelvic ultrasound

c)     Hormone levels

d)    Hysterosalpingogram

e)    Post-coital test

f)      Endometrial biopsy

2)    Any other service required for the diagnosis or treatment of infertility, or of any associated disease whose manifestation is infertility, is not covered.

3)    Some QualChoice administered plans, especially self-insured plans, offer somewhat broader coverage for infertility. For further information on such coverage:

a)    If you are enrolled in the Federal Employees Health Benefit Program, please see medical policy 244 that deals with the infertility coverage in that plan.

b)    Consult your plan’s coverage documents; or

c)     View a summary description of your plan at www.qualchoice.com; or

d)    Call our Customer Service line.


Medical Statement

1)    For instructions regarding administration of the FEHBP infertility benefit, please go to medical policy BI244.

2)    QualChoice covers a limited diagnostic work-up for infertility, which is designed to screen for basic problems that might cause infertility.  This benefit is limited to a maximum of one each of the following tests per lifetime:

i)     Semen analysis

ii)    Pelvic ultrasound

iii)   Hormone levels

iv)   Hysterosalpingogram (Exception: HSG is allowed three months after placement of Essure permanent contraceptive device to insure appropriate placement, even in women who have had a previous HSG)

v)    Post-coital test

vi)   Endometrial biopsy

3)    Any other services required for the diagnosis or treatment of infertility, or of any associated disease whose predominant manifestation is infertility, is not covered. Claims for non-covered services will result in the return of an EOB indicating no member financial responsibility. If the physician and patient agree on a course of diagnosis and treatment of infertility that is not covered, the physician should obtain a procedure-specific acknowledgement of financial responsibility from the patient before performing any tests or procedures.

4)    QualChoice will not cover services for treatment of infertility such as: artificial insemination, in-vitro fertilization, fertility drugs, sonograms, SCORIF (Stimulated Cycle Oocyte Retrieval Intravaginal Fertilization), IVC (intravaginal culture), GIFT or other infertility procedures.

5)    QualChoice will not cover any medications, procedures, or other services for treatment of infertility, no matter whether diagnostic or therapeutic, or whether by natural, artificial, mechanical, pharmacological or other means. QualChoice will not cover the treatment of any disease whose only significant manifestation is infertility. QualChoice will also not cover services to alter, restore or promote function or structural anatomy of any reproductive organs for the predominant purpose of restoring fertility.

6)    Diagnostic procedures or tests performed after a diagnosis of infertility has been confirmed will not be covered. 

7)    Diagnostic procedures or tests that are related to the treatment of infertility will not be covered.  Repetitive diagnostic testing to confirm the effectiveness of fertility medications will not be covered. Testing of a pregnancy resulting from infertility treatment to assure the number, location and viability of embryos is also not covered.

 

CPT CODES USED IN THIS BI

58321

artificial insemination – cervix

58322

artificial insemination – uterus

58323

sperm washing

58340

HSG

58345

Hydrotubation

58350

Chromotubation

58559

Hysteroscopy lysis of adhesions

58560

             "             division of septum

58565

 

58660

Laparoscopic Lysis of adhesions

58662

Laparoscopic fulgurate adhesions

58672

Laparoscopic fimbrioplasty

58673

             "            salpingostomy

58679

Unlisted

58740

Lysis of adhesions

58750

tubotubal anastomosis

58752

tubo-uterine anastomosis

58760

Fimbrioplasty

58770

Salpingostomy

58970

IVF oocyte retrieval

58974

IVF embryo transfer

58976

IVF – GIFT

58999

unlisted female genital

59866

multifetal pregnancy reduction

74740

HSG (radiology charge)

76831

Sonohysterography

82670

Estradiol; total (code revised eff 01-01-2021)

83001

Gonadotropin (FSH)

83002

Gonadotropin (LH)

89250

culture of oocyte

89251

culture of embryo

89253

assisted embryo hatching

89254

oocyte identification, follicle

89255

prep of embryo for transfer

89257

sperm ident from aspirate

89258

cryopreservation of embryos

89259

cryopreservation of sperm

89260

sperm isolation

89261

complex sperm preparation

89264

sperm from testicle tissue

89268

insemination of oocytes

89272

extended culture of oocytes

89280

assisted oocyte fertilization

89281

>10

89290

biopsy oocyte polar body

89291

>5

89300

Semen Analysis (incl Huhner)

89310

" (no Huhner)

89320

Semen Analysis, Complete

89321

Semen Analysis, presence or motility

89325

Sperm Antibodies

89329

Sperm Evaluation, lamster ovum penetration

89330

            "          ,   cervix mucus penetration

89335

cryopreservation of testis

89342

storage – embryos

89343

storage – sperm

89344

storage - reproductive tissue

89346

storage – oocytes

89352

thaw embryos

89353

thaw sperm

89354

thaw reproductive tissue

89356

thaw oocytes

A4264

Perm implantable contraceptive  device

J3355

Inj urofollitropin

S0122

Inj menotropins

S0126

Inj follitropin alfa

S0128

Inj follitropin beta

S4011

IVF Package

S4013

Compl GIFT Case Rate

S4014

Compl ZIFT Case Rate

S4015

Compl IVF Nos Case Rate

S4016

Frozen IVF Case Rate

S4017

IVF Canc A Stim Case Rate

S4018

F EMB Trns Canc Case Rate

S4020

INF Canc A Aspir Case Rate

S4021

IVF Canc P Aspir Case Rate

S4022

Asst Oocyte Fert Case Rate

S4023

Incompl Donor Egg Case Rate

S4025

Donor Serv IVF Case Rate

S4026

Procure Donor Sperm

S4027

Store Prev Froz Embryos

S4028

Microsurg Epi Sperm Asp

S4030

Sperm Pricure Init Visit

S4031

Sperm Pricure Subs Visit

S4035

Stimulated IUI Case Rate

S4037

Cryo Embryo Transf Case Rate

S4040

Monit Store Cryo Embryo 30 d


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

 

For coverage statements appropriate to the Federal Employees Health Benefit Program, see medical policy BI244.


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.