CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI)

This policy addresses intracytoplasmic sperm injection (ICSI), a laboratory fertilization technique used in assisted reproduction. ICSI is considered medically necessary for covered members for up to three cycles per attempted pregnancy when severe male-factor infertility is documented by semen analysis showing asthenozoospermia (<40% motile sperm), oligozoospermia (<15 million/mL), or teratozoospermia (≤4% normal morphology). It is not medically necessary beyond three cycles or when these criteria are not met, including in cases of unexplained infertility, tubal occlusion, or advanced maternal age.

"A maximum of three cycles of ICSI per attempted pregnancy is consideredmedically necessaryin covered individuals who meetANYof the following criteria:"

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