Transcription of Clinical Performance Guideline Medical Fertility Solutions ...
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This document is proprietary and confidential to Optum 2020. Effective 09/29/2020. Unauthorized use or copying without written consent is strictly prohibited. Printed copies are for reference only. TABLE OF CONTENTS 1 Clinical Performance Guideline Fertility Solutions Infertility Medical Necessity Guideline TABLE OF CONTENTS PURPOSE AND GOAL 2 BACKGROUND 2 GENERAL INDICATIONS 9 TREATMENT CRITERIA 10 OVULATION INDUCTION 10 CLOMID 10 LETROZOLE 10 GONADOTROPINS 11 OVARIAN STIMULATION 11 CLOMID 12 LETROZOLE 12 GONADOTROPINS 12 THERAPEUTIC DONOR INSEMINATION 14 INTRAUTERINE INSEMINATION 14 NATURAL CYCLE 14 STIMULATED IUI 14 ASSISTED REPRODUCTIVE TECHNOLOGIES 16 IVF 16 NATURAL CYCLE IVF 16 ICSI 17 IVF FRESH CYCLE NOT INDICATED 17 SURGICAL SPERM ASPIRATION 18
Clinical Performance Guideline Fertility Solutions Infertility Medical Necessity Guideline Purpose: To provide an understanding of infertility treatment, issues surrounding infertility surgery, and issues surrounding multiple embryo transfers among individuals faced with the potential loss of fertility.
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