Medical Policy Updates

Notification of Policy Revisions Effective April 14, 2020 (Posted February 11, 2020)

Medical Guidelines Reason for Update
Infertility Diagnosis and Treatment "Notification" Description section updated. When covered section updated to allow "Saline infusion sonohysterography (SIS or SHG)", "Anti-Mullerian hormone (AMH)", and endocrine evaluation to include "luteinizing hormone (LH), testosterone, and prolactin." Added "Please check the member's benefit booklet for information regarding pharmacy benefit coverage for infertility treatment, which may be separate from medical infertility coverage." to When covered section. "Non-steroidal aromatase inhibitor for medical conditions associated with infertility i.e. polycystic ovarian disease.” Added to basic treatments under When covered section. Reference values for semen analysis removed from When covered section. When covered section clarified Artificial Means of Conception with "Artificial insemination (AI), Intrauterine Insemination (IUI), and/or In Vitro fertilization (IVF)." Added "thawing of cryopreserved embryos" and "Assisted hatching" to Artificial Means of Conception in When covered section. Mechanically assisted fertilization (MAF) clarified to Intracytoplasmic Sperm Injection (ICSI) in When covered section. "Current American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART) guidelines regarding limits to the number of embryos transferred should be followed. (see Policy Guidelines)" added to When covered section. Removed "Administration of letrozole" from When not covered section. When not covered section relating to In Vitro Fertilization (IVF) and services associated with IVF rewritten to include "Charges related to cryopreservation of reproductive tissue, including sperm and oocytes, are not covered under standard medical benefits or under infertility benefits unless otherwise stated in the member's benefit booklet." Policy Guidelines section updated. References added. Coding section updated. Medical Director review 2/2020. Notification given 2/11/2020 for effective date 4/14/2020.