Policies

Gonadotropin Intrauterine Insemination (IUI) Policy 

Gonadotropin IUI: Intrauterine Insemination with the use of injectable stimulation hormone shots.

IUI cycles are approved with no medication or oral stimulation and trigger shot medication only.
All requests for gonadotropin (injectable stimulation) medications for an IUI cycle must be reviewed by a medical reviewer (who is a like specialist). IUI treatment with gonadotropin medications increases the risk of multiple pregnancies, therefore the use of Gonadotropin without counseling on alternative treatment options, including oral medications must comply with best practice guidelines. Read the full Gonadotropin IUI Policy.

Multiple Embryo Transfer (MET) Policy

Multiple Embryo Transfer: when more than one embryo is placed into the uterus at the time of transfer.

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 references ASRM in addition to current evidence based best practice guidelines. Read the full Multiple Embryo Transfer Policy.

Mock Cycle & Endometrial Receptivity Test Policy

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). Read the full Mock Cycle and Endometrial Receptivity Test Policy.

Embryo Banking Policy

After two embryo banking cycles have been completed and once three useable embryos are banked, no further embryo banking 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. Read the full Embryo Banking Policy.

Egg Banking Policy

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. 

Read the full Egg Banking Policy.

Repeated Cycle Cancellation Policy

After cancellation of two consecutive retrieval cycles due to poor response (ie: no usable eggs or no usable embryos resulting), no further retrieval cycles will be covered without review by an NPUA medical reviewer.  
Requests for additional retrieval cycles must be reviewed by a medical reviewer (like specialist). 

Policy Details:  

• Usable embryo: Embryo available for transfer, cryopreservation or PGT biopsy attempt
• Usable egg: Mature (MII) egg/oocyte available for fertilization or cryopreservation 
• Cancelled retrieval cycle: Treatment discontinued either pre-retrieval due to inadequate response or post-retrieval due to absence of usable embryos/eggs

Read full Repeated Cycle Cancellation Policy.