Policies
Services related to the below policies require prior authorization through NPUA. Please ensure approval is received prior to proceeding with services to confirm coverage. Please reference your plan documents to understand what’s covered through your organization.
Gonadotropin IUIs (all)
IUI cycles are approved with no medication or oral stimulation and trigger shot medication only.
Requests for gonadotropin (injectable stimulation) medications for an IUI cycle must be reviewed by a medical reviewer (like specialist). IUI treatment with gonadotropin medications increase the risk of multiple pregnancies, the use of Gonadotropin without counseling on alternative treatment options, including oral medications must comply with ASRM guidelines. Please see, Practice Committees of the American Society for Reproductive Medicine and Society for Reproductive Endocrinology and Infertility. Use of exogenous gonadotropins for ovulation induction in anovulatory women: a committee opinion. Fertility and Sterility. January 2020. Practice Committee of the Society for Reproductive Endocrinology and Infertility, Quality Assurance Committee of the Society for Assisted Reproductive Technology, and the Practice Committee of the American Society for Reproductive Medicine. Multiple gestation associated with infertility therapy: a committee opinion. Fertility and Sterility. March 2022.
SET Policy (all)
Transfer cycles are approved for single embryo transfer.
If the ordering physician believes that transfer of multiple embryos is indicated, they must attest that the transfer follows current published evidence-based guidelines. Multiple Embryo Transfers that do not meet the clinical policy will be reviewed for medical necessity by a like specialist (MD). NPUA follows ASRM guidelines.
Mock Cycle & Endometrial Receptivity Test
Mock cycles and ERA are covered only for those who meet medical necessity criteria.
Medical necessity is limited to those using donor tissue, having history of failed implantation or recurrent pregnancy loss (defined as two or more pregnancy losses), or having only one useable embryo remaining. Requests for mock cycle coverage not meeting this criteria must be reviewed by a medical reviewer (like specialist).
Embryo banking
Once three useable embryos are banked, no further IVF cycles will be covered until transfer is attempted.
Additional embryo banking cycles may not be authorized once a maximum of three usable embryos have been cryopreserved. Requests for additional embryo banking cycles must be reviewed by a medical reviewer (like specialist).
Policy Details: Usable embryo: A day 3, 5 or 6 embryo that is either (i) deemed “usable” by embryology lab if no PGT testing has been performed; of (ii) a euploid embryo if PGT-A testing has been performed.
Oocyte Banking
After two egg freezing cycles, a third will not be authorized once a 90% probability of live birth has been met.
After two cycles, an additional egg banking cycle cannot be authorized once a maximum of a 90% probability of a live birth is met as determined by egg freezing data. Requests for additional oocyte banking cycles must be reviewed by a medical reviewer (like specialist). NPUA uses the following tool to determine the probability of live birth based on individual circumstances. Egg Banking Calculator: BWH Egg Freezing Counseling Tool (EFCT)
This calculator has been peer reviewed and uses the following calculation: Dr. Janis Fox, MD, Dr. Randi Goldman MD, Dr. Malinda Lee MD, Brigham Women’s Hospital Egg Freezing Counseling Tool (EFCT) p(Livebirth) = 1 – [1 – 0.6 × p(Euploid) × p(Blast)] ^ (Number of mature eggs) where p(Blast) = 0.95 × exp(2.8043 – 0.1112 × Age) if Age <36 and p(Blast) = 0.95 × exp(2.8043 – 0.1112 × Age) if Age <36 Published MDCalc Ltd. Inc. October, 2017.
In addition to these policies, some benefits have other requirements. For Progyny, click here.