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).

Definitions

• 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

Utilization Review Trigger

Utilization review will only be required under this policy after a member has undergone at least two retrieval attempts under their current Progyny benefit AND if the two most recent retrieval attempts resulted in cancelled cycles due to:

• Poor response (pre-retrieval cancelled cycle including conversion to IUI) OR
• No usable eggs (post-retrieval) OR
• No usable embryos (post retrieval)

Consideration for Approval

Members who are not menopausal and who currently have decreased ovarian reserve whose two most recent retrieval attempts resulted in cancelled cycles may be approved for an additional retrieval cycle when:

1. No more than one retrieval cycle was cancelled prior to egg collection due to poor response
   AND/OR
2. No more than one cancelled cycle occurred post-retrieval due to zero usable embryos or eggs
   AND/OR
3. Demonstrated follicular development: At least one recent cancelled cycle showed evidence of adequate ovarian response (minimum 3 dominant follicles ≥14mm diameter with corresponding estradiol levels)

CPT Codes Impacted by Policy

Progyny CPT Code	CPT Code Definition
S4020	Cycle Monitoring (Before Aspiration – IVF/EF)
S4021	Partial Cycle (After Aspiration, No Fert – IVF/EF)
S4021-22	Partial Cycle (w/Fert – IVF)
S4035	IUI (applicable if result of IVF Conversion)

Documentation:

1. Previous retrieval cycle stimulation sheets [including hormones and follicular ultrasound reports as well as embryology reports];
2. Ovarian reserve testing [within the past year: AMH; day 2/3 e/fsh; antral follicle count]
3. Pertinent clinical history [including last spontaneous menses date, prior pregnancies whether conceived without or with medical assistance and approximate dates [year only] and outcomes.

References

1. Bayefsky MJ, Cascante SD, McCulloh DH, Blakemore JK. Live birth rates in in vitro fertilization cycles with five or fewer follicles. J Assist Reprod Genet. 2024 Jan;41(1):223-229. doi: 10.1007/s10815-023-02985-8. Epub 2023 Nov 18. PMID: 37978117; PMCID: PMC10789701.
2. Devesa M, Tur R, Rodriguez I, Coroleu B, Martinez F, Polyzos NP. Cumulative live birth rates and number of oocytes retrieved in women of advanced age. A single centre analysis including 4500 women >=38 years old. Hum Reprod 2018;33:2010–7
3. Drakopolous P, Blockeel C, Stoop D et al. Conventional ovarian stimulation and single embryo transfer for IVF/ICSI. How many oocytes do we need to maximize cumulative live birth rates after utilization of all fresh and frozen embryos? Hum Reprod. 2016;31:370-6.
4. Fertility Treatment When the Prognosis Is Very Poor or Futile: an Ethics Committee Opinion. Fertil Steril 2019;111:659–63.
5. Gleicher N, Vega, MV, Darmon SK et al. Live-birth rates in very poor prognosis patients, who are defined as poor responders under the Bologna criteria, with nonelective single embryo, two-embryo. And three or more embryos transferred. Fertil Steril 2015;104:1435-41.
6. Seifer DB, Wang SF, Frankfurter D. Cumulative live birth rate with autologous oocytes plateau with fewer number of cycles for each year of age >42. Repro Biol and Endocrinol.2023 21:94.