Policies

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).  

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. 

MET that do not meet the clinical policy will be reviewed for medical necessity by a like specialist (MD).

Mock Cycle & Endometrial Receptivity Test (all)

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 having 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). 

Oocyte Banking

After two egg freezing cycles, a third will not be authorized once a 75% probability of live birth has been met. 
After two cycles, an additional egg banking cycle cannot be authorized once a maximum of a 75% 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).