Fertility Coverage Details

Infertility is the medically documented diminished ability to conceive or induce conception. A couple is considered infertile if pregnancy does not occur over a one-year period of normal coital activity between a male and female partner without contraceptives. The cause of infertility can be a female or male factor, or a combination of both.

Typical examples of fertility enhancement methods include but are not limited to ovulation induction using hormone injections, tuboplasty for the female, and/or microsurgical reconstruction for the male.

Assisted fertilization refers to those techniques used to enhance sperm-egg interaction.

When attempts to achieve pregnancy through normal coital activity are unsuccessful, the cause of the infertility must be established. Before beginning any medical or surgical treatment to enhance fertility, the patient may undergo an ultrasound examination. Like all other medical, surgical and diagnostic services performed to diagnose and treat infertility, diagnostic ultrasound is generally covered based on the member's benefits.

A complete pelvic or transvaginal ultrasound study is eligible at the beginning of an infertility assessment. Once the infertility treatment has been initiated, limited ultrasound studies performed during the treatment are also eligible. However, a complete ultrasound study performed during the treatment is typically not medically necessary. Individual consideration may be given to those situations wherein the patient's clinical records document the medical necessity for a complete ultrasound during treatment.

When conception does not result from the fertility enhancing treatment, menstruation will occur. If the patient pursues further medical or surgical treatment for infertility, another complete ultrasound study is eligible to reassess the patient's status before a new episode of infertility treatment begins.

When medical or surgical treatment of the infertile patient is unsuccessful in achieving pregnancy, and it has been established that the ultimate goal for the infertile patient is assisted fertilization (AI, IVF, GIFT, ZIFT, etc.), all subsequent diagnostic, medical and surgical services are considered part of the assisted fertilization program, and are non-covered when the member does not have an assisted fertilization benefit.

Ultrasound studies performed in connection with an assisted fertilization program are generally not covered unless the member's benefits include assisted fertilization. Refer to Highmark Medical Policy Bulletin U-5 for further information on coverage for assisted fertilization techniques and related services including ultrasound studies.

Assisted fertilization techniques are generally limited to those infertile couples who do not respond to standard medical or surgical treatment for infertility.