89398
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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
- Cryopreservation of mature oocytes is consideredmedically necessarywhen the following criteria are met:Individual is a candidate based on ovarian reserve and likelihood for successful oocyte cryopreservation (for example, age 45 years or less);andPost-pubertal;andFacing anticipated infertility resulting from medical or surgical treatment, including chemotherapy, radiation therapy, other gonadotoxic therapies, or bilateral oophorectomy;andAnticipated infertility is NOT the result of the following [...]
- Individual is a candidate based on ovarian reserve and likelihood for successful oocyte cryopreservation (for example, age 45 years or less);and
- Post-pubertal;and
- Facing anticipated infertility resulting from medical or surgical treatment, including chemotherapy, radiation therapy, other gonadotoxic therapies, or bilateral oophorectomy;and
- Anticipated infertility is NOT the result of the following:Sterilization services, when not for treatment of an illness, injury or disease or its symptoms;orNormal reproductive aging.
- Sterilization services, when not for treatment of an illness, injury or disease or its symptoms;or
3 Active Policies
AMBETTER-CP.MP.130 — Fertility Preservation
ANTHEM-LAB.00045 — LAB.00045 Selected Tests for the Evaluation and Management of Infertility
ANTHEM-CG-MED-66 — CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue
Related Codes
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