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399 Revolution Drive, Suite 810, Somerville, MA 02145 | AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company 1 Medical Policy assisted Reproductive Services/Infertility Services Document Number: 002 *Commercial and Qualified Health Plans MassHealth Authorization required X No notification or authorization Not covered X *Not all commercial plans cover this service, please check plan s benefit package to verify coverage. Contents Overview .. 2 Coverage Guidelines .. 2 MassHealth, and Certain Custom Plans .. 2 Covered Services/Procedures .. 3 General Eligibility Coverage Criteria .. 3 SERVICE -SPECIFIC INFERTILITY COVERAGE FOR MEMBERS WITH UTERI and OVARIES .. 5 Artificial Insemination (AI)/Intrauterine Insemination (IUI) .. 5 Conversion from IUI to In Vitro Fertilization (IVF) .. 6 In Vitro Fertilization (IVF) for Infertility .. 6 A. General Eligibility Coverage Criteria .. 6 B.

utilizes to determine medical appropriateness for assisted reproductive services including infertility services. This document does not address the coverage or criteria for the treatment of the underlying medical condition causing the infertility. Infertility is the condition of an individual who is unable to conceive or produce conception during a

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