TREATMENT OF INFERTILITY - Oxford Health Plans

TREATMENT OF INFERTILITYCLINICAL POLICYPolicy Number: INFERTILITY 001.19 T2Effective Date: October 1, 2013Table of ContentsCONDITIONS OF COVERAGE...................................DESCRIPTION OF SERVICE…………………………..POLICY AND RATIONALE…………………................TREATMENT/APPLICATION GUIDELINES...............PAYMENT GUIDELINES.............................................REFERENCES............................................................POLICY HISTORY/REVISION INFORMATION..........Policy History Revision InformationPage1333689Related Policies:• Diagnostic (Basic)Procedures for Infertility• Follicle StimulatingHormones (FSH) Used inthe Treatment of Infertility• Infertility ProceduresRequiring Notificationand/or Precertification• Treatment of Infertility forConnecticut Groups• Treatment of Infertility forNew Jersey LargeGroups• Treatment of Infertility forNew Jersey SmallGroups• Treatment of Infertility forNew York Large andSmall GroupsThe services described in Oxford policies are subject to the terms, conditions and limitations of theMember's contract or certificate. Unless otherwise stated, Oxford policies do not apply to MedicareAdvantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary withoutprior written notice unless otherwise required by Oxford's administrative procedures or applicable state law.The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for thesepolicies.Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to theMember's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if thereare any exclusions or benefit limitations applicable to any of these policies. If there is a difference betweenany policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate ofCoverage will govern.CONDITIONS OF COVERAGEApplicable Lines of Business/ProductsThis policy applies to Oxford Commercial plan and OxfordUSA plan membership excluding:• New Jersey Large - please refer to Treatment ofInfertility for New Jersey Large Groups.• New York Large and Small (excluding Healthy New YorkPlans) - please refer to Treatment of Infertility for NewYork Large and Small Groups.• Connecticut Large and Small - please refer to Treatmentof Infertility for Connecticut Groups.• New Jersey Small Group Plans (except NJ Small PlanA) - please refer to Treatment of Infertility for NewJersey Small Groups.Treatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC1

Applicable Lines of Business/Products(continued)Benefit Type Infertility benefit 1, 2Pharmacy benefit 3Referral RequiredYes 4(Does not apply to non-gatekeeperproducts)Authorization Required(Precertification always required forinpatient admission)Precertification with MedicalDirector Review RequiredApplicable Site(s) of Service(If site of service is not listed, MedicalDirector review is required)Special Considerations• The below Lines of Business (LOBs) do NOT haveinfertility benefits beyond what is covered underdiagnostic (basic) coverage and are excluded fromcoverage. Please refer to policy Diagnostic (Basic)Procedures for Infertility:o All Healthy NY Planso All NY Individual planso NJ Small Plan A and NJ Individual plansYesNo 5Outpatient, Office1 The Member may or may not have coverage for out-ofnetworktreatment.2 Advanced Infertility benefits are specific to each group.Refer to Member's benefits.3 Pharmacy benefit with coverage for injectable infertilitymedications.4 Referral is ONLY required if the treating physician is NOTthe OBGYN of record.5 Precertification with MD review is required for any codelisted in the non-covered grid and may be required for codesin the covered grid.Note:• Oxford has engaged OptumHealth to perform reviews of requests for pre-certification. To precertifya procedure related to the treatment of infertility, please call OptumHealth at 877-512-9340.• Oxford continues to be responsible for decisions to limit or deny coverage and for appeals.• Also refer to Infertility Procedures Requiring Notification and/or Precertification.• Treatment of infertility is not a covered benefit for all plans. Refer to Member's benefits.• Diagnosis of infertility is a covered benefit for all plans. Refer to Diagnostic (Basic)Procedures for Infertility.• For those plans that have infertility coverage, the infertility benefit has specific dollar and/orprocedural coverage limitations based on the Member's individual coverage.• Members should refer to their Certificate of Coverage for their specific coverage and theirSummary of Benefits for out of pocket expenses including maximums and benefit limitations.• If the Member's coverage is subject to a pre-existing condition limitation, infertility will beconsidered a pre-existing condition (except for CT).• Religious employer exemptions may apply. Refer to Member's benefits.• Self-funded groups may or may not choose to offer infertility coverage. Refer to Member'sbenefits.• For coverage guidelines for FSH, refer to Follicle Stimulating Hormones (FSH) Used in theTreatment of Infertility.Treatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC2

DESCRIPTION OF SERVICE/BACKGROUND INFORMATIONInfertility is defined as the inability to achieve pregnancy after 12 months (6 months if the femaleis 35 or older) of unprotected heterosexual coitus (sexual intercourse), or following an MDsupervised donor insemination. Approximately 10-15% of American couples experience infertility.A female factor is responsible for approximately 50% of cases, while male factors account for upto 30%. Multiple causes are found in a number of cases. In up to 15% of cases, no obvious causecan be identified.POLICY AND RATIONALEOxford will cover treatment of infertility for eligible Members within the limit of the Member'sbenefit as stated in Treatment/Application Guidelines.TREATMENT/APPLICATION GUIDELINESOxford has engaged OptumHealth to to perform reviews of requests for the treatment of infertility.Optum has established an infrastructure to support the review, development, and implementationof comprehensive clinical guidelines. The guidelines are available on the OptumHealth web site:https://www.myoptumhealthcomplexmedical.com/gateway/public/infertility/productsAndServices.jspOxford recognizes diagnostic and assisted reproductive technologies (ART).Diagnostic services are covered under the Base medical benefit for all Oxford plans. An InfertilityBenefit is not required for coverage of these services. Refer to policy: Diagnostic (Basic)Procedures for Infertility.Procedures to Treat Infertility:Assisted reproductive services include mid level fertility enhancing techniques (from cyclestimulation up to and including artificial insemination) and the more technologically complexadvanced services. Assisted reproductive technologies (ART) require an infertility benefit and notall groups or plans have coverage for assisted reproductive services; additionally some groupshave coverage for mid level infertility techniques, but not for advanced services. Refer to theMember's benefits.Comprehensive Level (also referred to as Mid Level) techniques:• Cycle stimulation with oral or injectable medications;• Intrauterine artificial insemination;• Sperm washing;• Sperm isolation; simple prep (e.g. sperm wash and swim up);• Sperm isolation; complex prep (e.g. Percoll gradient, albumin gradient);• Sperm evaluation; hamster penetration test;Advanced Level Techniques:• In vitro fertilization (IVF);• Gamete intrafallopian transfer (GIFT);• Thawing of cryopreserved embryo;• Microscopic epididymal sperm aspiration (MESA);• Testicular sperm aspiration (TESA);• Percutaneous epididymal sperm aspiration (PESA);• Assisted oocyte fertilization, microtechnique;• Culture of oocyte(s)/embryo(s);Treatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC3

• Assisted oocyte fertilization, microtechnique;• Assisted embryo hatching, microtechniques;• Oocyte identification from follicular fluid;• Preparation of embryo for transfer (any method);• Sperm identification from aspiration (other than seminal fluid);• Ultrasonic guidance for aspiration of ova, imaging and supervision;• Intracytoplasmic sperm injection. (ICSI)Religious Employer:A religious employer may request a contract without coverage for infertility services (e.g., in vitrofertilization, embryo transfer, artificial insemination and intracytoplasmic sperm injection [ICSI])that are contrary to the religious employer's bona fide religious tenets.• Note: A religious employer is defined in CT as an employer that is a "qualified churchcontrolledorganization" as defined in 26 USC 3121 or a church-affiliated organization.EligibilityIn order to be eligible for infertility benefit coverage the Member must meet infertility, agecoverage and prior procedure criteria listed below:1. Infertility Criteria (must meet one):o Inability to achieve pregnancy after 12 months of unprotected heterosexualintercourse oro Women aged 35 and older who are unable to achieve pregnancy after 6 monthsof unprotected heterosexual intercourse oro Women with documented follicle stimulating hormone (FSH) levels less than orequal to 19 mIU/ml on day 3 of the menstrual cycle oro Women who have not met time criteria for failure to conceive, but who have adocumented anatomic variant resulting in the inability to achieve pregnancy (e.g.,severe pelvic inflammatory disease, endometriosis, or ectopic pregnancyrequiring surgical removal of both fallopian tubes) oro Males with anatomical variants such as aspermia or varicocele resulting in aninability to reproduce.2. Age criteria- applies to Member being treated [(male or female) (must meet both)]:o Minimum age is 21 years ando Maximum age is 44 years• Exception: If an eligible Member has initiated a cycle of treatment and,by virtue of having a birthday, exceeds the maximum eligible age prior tocompletion of the cycle, the treatment will be covered to the nearestlogical endpoint:ooFor Artificial Insemination: Ovulation induction initiated prior tobirthday: ovulation induction in progress and subsequentinsemination will be covered.Other Advanced Procedures (e.g. IVF, GIFT, etc): Cyclestimulation initiated prior to birthday: cycle stimulation inprogress, subsequent ovum retrieval, fertilization, culture andembryo transfer will be covered unless the benefit has beenexceeded.3. Coverage criteria (must meet all):o Treatment is limited to Oxford insured Members ando Benefit has not been exceeded andTreatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC4

o• Note: Benefits are defined by the number of procedures and/or byfinancial caps. Once the maximum benefit (as defined by the Member'splan) has been reached, there is no extension of service, even if cyclestimulation has been initiated.Preexisting conditions does not applyNote:• Congenital abnormalities may not be excluded as a preexistingcondition.• Infertility may not be considered pre-existing in CT.4. Prior procedure criteria (must meet one):o Female Members requesting in vitro fertilization (IVF) andgamete intrafallopiantransfer (GIFT) must have• Used all reasonable, less expensive and medically appropriatetreatments or;• Have not been able to become pregnant or carry a pregnancyNon-Covered ServicesTreatments not covered by Oxford are as follows:• Cost of donor sperm or an ovum donor when oocyte retrieved from someone other thanrecipient;• Sperm, embryo(s), reproductive tissue, testicular/ovarian, oocyte storage costs;• Cryopreservation of embryos, oocytes (eggs), sperm or other reproductive tissue;• Ovulation predictor kits;• Reversal of permanent sterilization procedures;• Cloning;• Sex change procedures;• Any infertility services if the Member (or partner) has undergone a voluntary sterilizationprocedure (tubal ligation, fulguration, vasectomy, Essure ® insertion);• Services for partner, spouses, and the maternity expenses of gestational carriers notinsured by Oxford.• All costs associated with surrogate motherhoodo Note: Maternity services are covered for Oxford Members acting as surrogates.PAYMENT GUIDELINESThe codes listed in this policy are for reference purposes only and is not meant to be an allinclusive list of procedure codes to diagnose or treat infertility. Listing of a service or device codein this policy does not imply that the service described by this code is a covered or non-coveredhealth service. Coverage is determined by the Member’s plan of benefits or Certificate ofCoverage. This list of codes may not be all inclusive.Codes below marked with (*) accumulate toward the Members' individual infertility benefitCodes below marked with (**) are covered for NJ LargeCovered CodesCPT ® CodeDescription52402 Cystourethroscopy with transurethral resection or incision of ejaculatory ducts55200Vasotomy, cannulization with or without incision of vas, unilateral or bilateral(separate procedure)55300 Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateralTreatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC5

or bilateral55550 Laparoscopy, surgical, with ligation of spermatic veins for varicocele55870 Electroejaculation58321* Artificial insemination; intra-cervical58322* Artificial insemination; intra-uterine58323* Sperm washing for artificial insemination58340Catheterization and introduction of saline or contrast material for saline infusionsonohysterography (SIS) or hysterosalpingography58345Transcervical introduction of fallopian tube catheter for diagnosis and/or reestablishingpatency (any method), with or without hysterosalpingography58350 Chromotubation of oviduct, including materials58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)58720Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separateprocedure)58740 Lysis of adhesions (salpingolysis, ovariolysis)58752 Tubouterine implantation58760 Fimbrioplasty58770 Salpingostomy (salpingoneostomy)58970* Follicle puncture for oocyte retrieval, any method58974* Embryo transfer, intrauterine58976* Gamete, zygote, or embryo intrafallopian transfer, any method76948* Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation82670 Estradiol83001 Gonadotropin; follicle stimulating hormone (FSH)83002 Gonadotropin; luteinizing hormone (LH)8827289290Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells (eg,for derivatives and markers)Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantationgenetic diagnosis); less than or equal to 5 embryos89250* Culture of oocyte(s)/embryo(s), less than 4 days;89253* Assisted embryo hatching, microtechniques (any method)89254* Oocyte identification from follicular fluid89255* Preparation of embryo for transfer (any method)89257* Sperm identification from aspiration (other than seminal fluid)89260*89261*Sperm isolation; simple prep (eg, sperm wash and swim-up) for insemination ordiagnosis with semen analysisSperm isolation; complex prep (eg, Percoll gradient, albumin gradient) forinsemination or diagnosis with semen analysis89264* Sperm identification from testis tissue, fresh or cryopreserved89268* Insemination of oocytes89272* Extended culture of oocyte(s)/embryo(s), 4-7 days89280* Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes89281* Assisted oocyte fertilization, microtechnique; greater than 10 oocytes89290*89291*Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantationgenetic diagnosis); less than or equal to 5 embryosBiopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantationgenetic diagnosis); greater than 5 embryos89352* Thawing of cryopreserved; embryo(s)HCPCS CodeDescriptionS4011*In vitro fertilization; including but not limited to identification and incubation ofmature oocytes, fertilization with sperm, incubation of embryo(s), and subsequentvisualization for determination of developmentS4013* Complete cycle, gamete intrafallopian transfer (GIFT), case rateS4014* Complete cycle, zygote intrafallopian transfer (ZIFT), case rateS4015* Complete in vitro fertilization cycle, not otherwise specified, case rateS4016* Frozen in vitro fertilization cycle, case rateTreatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC6

6. Centers for Disease Control and Prevention, American Society for Reproductive Medicine,and RESOLVE-1996. Assisted reproductive technology success rates: national summary andfertility clinic reports. Atlanta, GA: Centers for Disease Control and Prevention, 1998.7. Hanson MA, Dumesic DA. Initial evaluation and treatment of infertility in a primary caresetting. Mayo Clin Proc. 1998 Jul; 73(7): 681-5.8. La Sala GB, Montanari R, Dessanti L, et al. The role of diagnostic hysteroscopy andendometrial biopsy in assisted reproductive technologies. Fertil Steril. 1998 Aug; 70(2): 378-80.9. American College of Obstetricians and Gynecologists. Guidelines for women's health care,1996.10. Mosgaard B, Hertz J, Steenstrup BR, et al. Surgical management of tubal infertility: a regionalstudy. Acta Obstet Gynecol Scand. 1996; 75(5): 469-74.11. Silverberg KM. Ovulation induction in the ovulatory woman. Sem Reprod Endocrinol. 1996;14(4): 339-44.12. American College of Obstetricians and Gynecologists. Infertility. ACOG Technical Bulletin#125, 1989.13. The Certificates and Riders (NY, CT and NJ Large).14. CMS Intermediary Manual Part 3. Chapter II-Coverage of Services. Section 3101.13.15. NY Ins. Law §3221 6(A).16. New Jersey 17B: 27-46.1x.POLICY HISTORY/REVISION INFORMATIONDate10/01/2013Action/Description• Routine review; no content changes• Archived previous policy version INFERTILITY 001.18Treatment of Infertility: Clinical Policy (Effective 10/01/2013)©1996-2013, Oxford Health Plans, LLC8