Highmark Commercial Medical Policy - Pennsylvania |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
In Vitro Fertilization (IVF) IVF may be considered medically necessary when ALL of the following criteria are met:
AND
AND
Gamete Intrafallopian Transfer (GIFT)/Zygote Intrafallopian Transfer (ZIFT) GIFT or ZIFT may be considered medically necessary when ALL of the following criteria are met:
Intracytoplasmic Sperm Injection (ICSI) ICSI may be considered medically necessary when the individual has diagnosed infertility due to a male factor (e.g., low sperm count, low function of sperm, abnormal morphology of the sperm, obstructive azoospermia, and nonobstructive azoospermia), as defined by values based on the World Health Organization (WHO) semen-analysis criteria values, demonstrated on at least two separate semen analyses. Gamete/Oocyte Cryopreservation
Assisted reproductive technology for the purpose of gamete/oocyte cryopreservation is considered not medically necessary when the procedure is performed to:
Tubal Embryo Transfer (TET) TET may be considered medically necessary when the member meets the definition of infertility and ALL of the following criteria are met:
Frozen Embryo Transfer (FET) FET may be considered medically necessary when the member meets the definition of infertility and EITHER of the following criteria is met:
Ovulation Induction Management Ovulation induction management (cycle management) involves the medical management of the patient where medication is used to stimulate development of mature follicles within the ovaries. It may be performed as part of an assisted fertilization program or as a treatment for infertility outside of an assisted fertilization program. This service may be reported using an appropriate evaluation and management procedure code; provided that there is patient/physician interaction and all of the components of the evaluation and management (E&M) code have been met. Ovulation induction management performed without a face-to-face patient/physician encounter (e.g., conducted via telephone) may be considered an eligible service. When performed for treatment of infertility, global payment for non-face-to-face ovulation induction management is limited to twelve times (12 cycles) within a twelve (12) month period. When assisted fertilization is successful, payment can be made for managing the pregnancy and delivery. Immunotherapy for Recurrent Fetal Loss Immunologic-based therapies to avoid recurrent spontaneous abortion are considered experimental/investigation and, therefore, non-covered due to the lack of scientific evidence for efficacy and safety. The procedures listed on the Table Attachment, Table A, are assisted fertilization procedures that may be reported as part of an assisted fertilization program. Refer to Table B, Laboratory Services, in the attachments for the quantity of laboratory services per cycle that may be considered medically necessary. More than two (2) progesterone measurements may be considered medically necessary for infertile women with irregular and prolonged menstrual cycles. For infertile women with regular menstrual cycles, a mid-luteal serum progesterone measurement (day 21 of a 28-day cycle) may be considered medically necessary. For infertile women with irregular menstrual cycles, this test would need to be repeated at the mid-luteal phase and weekly thereafter until the next menstrual cycle starts. Quantities of laboratory services that exceed the frequency guidelines listed on Table B, Laboratory Services, will be denied as not medically necessary. The following are non-covered professional services because there is no physician service rendered. Charges for cryopreservation, storage, procurement, and thawing of specimens are generally facility charges which should be processed in accordance with the member’s benefits:
The following reproductive techniques or services are considered experimental/investigational and, therefore, non-covered due to the lack of scientific evidence for efficacy and safety.
The following related services to reproductive technologies/techniques are considered not medically necessary:
Costs associated with the procurement of sperm, or harvesting of eggs and embryos from a donor. The following related services to reproductive technologies/techniques are considered not medically necessary:
Assisted reproductive technology services are generally excluded from standard medical-surgical contracts, and are not eligible for reimbursement. However, all medical, surgical, and diagnostic services performed to diagnose and treat infertility are generally covered unless the individual member’s contract contains exclusion with regard to the diagnosis and treatment of infertility. Once it has been established that the ultimate goal for the infertile patient is assisted reproductive technology (IVF, GIFT, ZIFT, etc.), all subsequent related diagnostic, medical, and surgical services are considered part of the assisted reproductive technology program, and are non-covered when the member does not have an assisted reproductive technology benefit. Related services, including but not limited to lab work and ultrasound, performed in preparation for or in conjunction with assisted reproductive technology services should be reported with the appropriate diagnosis code for IVF, GIFT, ZIFT, etc. in order to distinguish them as services associated with assisted reproductive technology program. Such services are non-covered when the member does not have the benefit for assisted reproductive technology. When reported, assisted reproductive technology program management should be processed under the appropriate procedure codes for the services rendered. Assisted reproductive technology program management generally includes, but is not limited to such services as:
Report the appropriate diagnosis code for IVF, GIFT, ZIFT, etc. in order to distinguish them as services associated with an assisted reproductive program. Such services are non-covered when the member does not have an assisted reproductive technology benefit. Gestational Carrier/Surrogate Medical services or supplies rendered to a gestational carrier or surrogate may be considered medically necessary if the member has ANY of the following indications:
Services provided to a surrogate or gestational carrier may be a benefit exclusion.
Assisted fertilization is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records. Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records. Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary. A network provider cannot bill the member for the non-covered service.
05/2015, Medical Criteria has been Added for Assisted Fertilization Techniques
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract. Discrimination is Against the Law The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. |