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.

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.

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.