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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. Certain Cigna Companies and/or lines of business only provide utilization review Services to clients and do not make coverage determinations.

• 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

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