S4026 — Procurement of donor sperm from sperm bank
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
- 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).
- ART performed by a physician board-certified or board-eligible in reproductive endocrinology for individuals with a female reproductive system; for those with a male reproductive system, performed by a board-certified or board-eligible urologist or reproductive endocrinologist.
1 Active Policy
AMBETTER-CP.MP.55 — Assisted Reproductive Technology
Related Codes
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