A9574
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Refills based upon documentation in cycle sheets.
- Benefit plan documentation: because "Some plans exclude infertility services for ovarian failure; please check benefit plan descriptions," documentation of plan-specific coverage determinations may be required.
- Semen analysis documentation: severe semen quantity or quality deficits require documentation on 2 separate occasions at least 2 weeks apart.
- For use of gonadotropin therapy in males (hypogonadotropic hypogonadism), documentation of normalization of serum testosterone levels is required prior to administration of recombinant follitropin for induction of spermatogenesis (policy text: "after normal serum testosterone levels are reached").
Key Coverage Criteria
- N98.1: Hyperstimulation of ovaries
- N99.83: Residual ovary syndrome
- Benign neoplasm and neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct (D35.2 - D35.3; D44.3 - D44.4)
- Neoplasm of uncertain behavior of female genital organs (D39.0 - D39.2)
- Neoplasm of uncertain behavior of other and unspecified male genital organs (D40.8 - D40.9)
- Iodine-deficiency related thyroid disorders and allied conditions (E01.8), subclinical iodine-deficiency hypothyroidism (E02), other hypothyroidism (E03.0 - E03.8)
1 Active Policy
AETNA-CPB-0327 — Infertility
Related Codes
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