S4015, Complete in vitro fertilization cycle, not otherwise specified, case rate
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Refer to pharmacy policy CP.PHAR.131 for prior authorization and documentation requirements for FDA‑approved infertility medications.
- Record verifying treating physician's board certification or board-eligible status in reproductive endocrinology (or urology for male reproductive system).
- Documentation that modifiable causes of infertility were evaluated and addressed when possible.
- Clinical documentation showing inability to conceive after required period of cycles exposed to sperm (12 months, or 6 months if female reproductive system age ≥35), including notes regarding prior IUI attempts if applicable.
Key Coverage Criteria
- PGT is covered when it is PGT-M or PGT-SR and the embryo is at increased risk of a single-gene disorder or structural chromosome rearrangement, with the condition causing significant health problems or severe disability; testing must use PCR, NGS (for rearrangements), or chromosomal microarray.
- Unexplained infertility in individuals with a female reproductive system aged ≥ 38 years.
- Diagnostic infertility services to determine the cause of infertility and guide treatment when the member's benefit plan specifically provides coverage for infertility services.
- Coverage may include evaluation and treatment related to a partner's infertility when the member's plan terms allow.
- ART services (including handling of oocytes, sperm, or embryos) performed solely for the treatment of infertility when all applicable ART policy criteria are met.
- Use of FDA‑approved medications for infertility (including specialty injectables) such as clomiphene, aromatase inhibitors, estrogens, corticosteroids, progestins, metformin, prolactin inhibitors, GnRH agonists/antagonists, and gonadotropins (see pharmacy policy CP.PHAR.131).
4 Active Policies
UHC-POL-preimplantation-genetic-testing, Preimplantation Genetic Testing and Related Services
AMBETTER-CP.MP.55, Assisted Reproductive Technology
UMR-POL-UMR-preimplantation-genetic-testing, Preimplantation Genetic Testing and Related Services
SUREST-POL-SUREST-preimplantation-genetic-testing, Preimplantation Genetic Testing and Related Services
Related Codes
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