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Infertility Services - Cigna

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Page 1 of 45 Medical Coverage Policy: 0089 Medical Coverage Policy Effective Date ........................................ ....10/15/2021 Next Review Date ....................................... 6/15/2022 Coverage Policy Number .................................. 0089 Infertility Services Table of Contents Overview ........................................ ...................... 1 Coverage Policy ........................................ ........... 1 General Background ........................................ .... 5 Medicare Coverage Determinations .................. 22 Coding/Billing Information .................................. 22 References ........................................ ................ 32 Related Coverage Resources Acupuncture Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis Hyperbaric Oxygen Therapy, Systemic & Topical Infertility Injectables Recurrent Pregnancy Loss: Diagnosis and Treatment Testosterone Therapy INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies.

• co-culturing of embryos/oocytes (i.e., culture of oocyte(s), embryo(s), less than 4 days with co-culture) • computer-assisted sperm motion analysis • direct intraperitoneal insemination, intrafollicular insemination, fallopian tube sperm transfusion

  Embryo

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