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Infertility Services - Cigna

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.

• sperm extraction and retrieval procedures such as: electroejaculation, microsurgical epididymal sperm aspiration (MESA), testicular sperm aspiration (TESA), testicular fine needle aspiration (TEFNA), testicular sperm extraction (TESE), microscopic-TESE, percutaneous epididymal sperm aspiration (PESA), vasal sperm aspiration, and seminal ...

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