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Infertility precertification updates

 

Precertification is required for certain infertility services, such as intrauterine insemination (IUI) and assisted reproduction techniques (ART), when a participating provider gives the service. Precertification includes a review of the member’s plan requirements for the use of infertility benefits and the medical necessity criteria in Aetna’s Clinical Policy Bulletin #0327, Infertility.   

 

This notice describes how we’re changing the authorization of IUI and ART during the precertification process. This benefit adjudication applies to requests received on or after January 1, 2019. This policy does not allow for retrospective cycle definition changes.  

 

Authorizations for IUI

Effective February 18, 2019: When approving precertification requests for IUI, we’ll authorize approvals up to the plan’s IUI cycle benefit maximum — generally six cycles per lifetime. For plans with unlimited cycle limits, we’ll authorize six cycles.      

 

This applies to the following: 

  • Current Procedural Terminology code 58322 

  • Healthcare Common Procedure Coding System code S4035 

 

Authorizations for ART  

Effective January 1, 2019, ART cycle-count definitions are as described in the chart below.

 

 

Procedure 

 

 

 

 

Cycle count  

 

 

 

 

One complete, fresh in vitro fertilization (IVF) cycle with transfer (egg retrieval, fertilization and transfer of embryo) 

 

 

 

 

One full cycle 

 

 

 

 

One fresh IVF cycle with attempted egg aspiration (with or without egg retrieval) but without transfer of embryo 

 

 

 

 

One-half cycle  

 

 

 

 

Fertilization of egg and transfer of embryo 

 

 

 

 

One-half cycle 

 

 

 

 

One cryopreserved (frozen) embryo transfer 

 

 

 

 

One-half cycle  

 

 

 

 

One complete GIFT cycle 

 

 

 

 

One full cycle 

 

 

 

 

One complete ZIFT cycle 

 

 

 

 

One full cycle  

 

 

 

You can also view these authorization changes on our provider website. After you log in, go to “Plan Central” and click “Aetna Claims Policy Information.” Then click “Policy Information” and go to “Benefit Guidance Statements.” Select the statement titled “Infertility.”