0375T
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Cross-reference: criteria related to cryopreservation are addressed in CP.MP.55 Assisted Reproductive Technologies (see that policy for cryopreservation requirements).
- For individuals with a female reproductive system aged ≥40 requesting retrieval of their own oocytes, documentation that the treating provider has evaluated: age, infertility risk factors, and a measure of ovarian reserve, and that the provider considers use of the member's own oocytes a viable strategy for attempting future conception.
- Documentation that the planned treatment causing risk to fertility is medically necessary.
- Clinical documentation supporting the diagnosis and planned gonadotoxic or fertility-threatening therapy (as referenced by policy sections I and III stating the treatment causing risk must be medically necessary).
Key Coverage Criteria
- Patients undergoing bilateral oophorectomy with risk of loss of fertility.
- Patients receiving gonadotoxic therapy (e.g., alkylating agents) with risk of infertility.
- Patients receiving cytotoxic chemotherapy that may impair future fertility.
- Patients receiving radiation therapy with potential gonadal exposure risking fertility loss.
- Patients with other iatrogenic causes that may transiently or permanently affect fertility.
- Ovarian stimulation and retrieval of oocytes for adults and adolescents with a female reproductive system prior to commencing medically necessary treatment likely to cause infertility (excluding voluntary sterilization).
2 Active Policies
PALMETTO-L38033 — Cervical Disc Replacement
JJ Part B
AMBETTER-CP.MP.130 — Fertility Preservation
Related Codes
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