Infertility is a problem or problems with the reproductive system that affects the ability to  conceive.  Different types of  reproductive problems affect men and women, but the end result is  the inability to  conceive or complete a pregnancy.  There are many reasons for infertility and  many different types of treatments. Even though an infertility treatment exists , it does not mean  it is covered ; the  member’s contract determines this . (Services to diagnose infertility  are covered  as a medical benefit.) This benefit coverage guideline lists types  of  services that may be  allowed if a member’s contract  covers infertility  treatments.

The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider  also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a  service may be covered

Coding Code Description 

Diagnostic  Services to Evaluate Potential Infertility

54500 Biopsy of testis, needle (separate procedure)
54505 Biopsy of testis, incisional (separate procedure)
54800 Biopsy of epididymis, needle
55200 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate  procedure)
55300 Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or  bilateral
55550 Laparoscopy, surgical, with ligation of spermatic veins for varicocele
8340 Catheterization and introduction of saline or contrast material for saline infusion  sonohysterography (SIS) or hysterosalpingography
58345 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography
58350 Chromotubation of oviduct, including materials
58540 Hysteroplasty, repair of uterine anomaly (Strassman type)
58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
58740 Lysis of adhesions (salpingolysis, ovariolysis)
58752 Tubouterine implantation
58770 Salpingostomy (salpingoneostomy)
58920 Wedge resection or bisection of ovary, unilateral or bilateral
74740 Hysterosalpingography, radiological supervision and interpretation
76831 Saline infusion sonohysterography (SIS), including  color flow Doppler, when performed
83001 Gonadotropin; follicle stimulating hormone (FSH)
83002 Gonadotropin; luteinizing hormone (LH)
89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)
89310 Semen analysis; motility and count (not including Huhner test)
89320 Semen analysis; volume, count, motility, and differential
89321 Semen analysis; sperm presence and motility of sperm, if performed
89322 Semen analysis; volume, count, motility, and  differential using strict morphologic  criteria (eg, Kruger)
89330 Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
89331 Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and  morphology, as indicated)


G0027 Semen analysis; presence and/or motility of sperm excluding Huhner
S3655 Antisperm antibodies test (immunobead)

Assisted Fertilization Services

If there is a difference between the information listed in the tables below  and the member’s  contract, the member’s contract prevails.

Ovulation Induction HCPCS

J0725 Injection, chorionic gonadotropin, per 1,000 USP units
J3355 Injection, urofollitropin, 75 IU
Q0115 Postcoital direct, qualitative examinations of vaginal or cervical mucous
S0122 Injection, menotropins, 75 IU
S0126 Injection, follitropin alfa, 75 IU
S0128 Injection, follitropin beta, 75 IU
S0132 Injection, ganirelix acetate, 250 mcg
S4022 Assisted oocyte  fertilization, case rate
S4042 Management of ovulation induction (interpretation of diagnostic tests and studies,  non  face – to – face medical management of the patient), per cycle

Intrauterine Insemination

58321 Artificial insemination; intra – cervical
58322 Artificial insemination; intra – uterine
58323 Sperm washing for artificial insemination
89260 Sperm isolation; simple prep (eg, sperm wash and swim – up) for insemination or  diagnosis with semen analysis
89261 Sperm isolation; complex prep (eg,  Percoll gradient, albumin gradient) for  insemination or diagnosis with semen analysis
89268 Insemination of oocyte

S4035 Stimulated intrauterine insemination (IUI), case rate
S3655 Antisperm antibodies test (immunobead)

Advanced  Reproductive/Fertilization Services
CPT 0357T Cryopreservation; immature oocyte(s)
58970 Follicle puncture for oocyte retrieval, any method
58974 Embryo transfer, intrauterine
76948 Ultrasonic guidance for aspiration of ova, imaging supervision and  interpretation
89250 Culture of oocyte(s)/embryo(s), less than 4 days
89251 Culture of oocyte(s)/embryo(s), less than 4 days; with co – culture of oocyte(s)/embryos
89253 Assisted embryo hatching, microtechniques (any method)
89254 Oocyte identification  from follicular fluid
89255 Preparation of embryo for transfer (any method)
89257 Sperm identification from aspiration (other than seminal fluid)
89258 Cryopreservation; embryo(s)
89259 Cryopreservation; sperm
89264 Sperm identification from testis  tissue, fresh or cryopreserved
89272 Extended culture of oocyte(s)/embryo(s), 4 – 7 days
89325 Sperm antibodies
89329 Sperm evaluation; hamster penetration test
89335 Cryopreservation, reproductive tissue, testicular
89337 Cryopreservation, mature  oocyte(s)
89342 Storage (per year); embryo(s)
89343 Storage (per year); sperm/semen
89344 Storage (per year); reproductive tissue, testicular/ovarian
89346 Storage (per year); oocyte(s)
89352 Thawing of cryopreserved; embryo(s)
89353 Thawing of  cryopreserved; sperm/semen, each aliquot
89354 Thawing of cryopreserved; reproductive tissue, testicular/ovarian
89356 Thawing of cryopreserved; oocytes, each aliquot

S4011 In vitro fertilization; including but not limited to identification and  incubation of  mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent  visualization for determination of development
S4015 Complete in vitro fertilization cycle, not otherwise specified, case rate
S4016 Frozen in vitro  fertilization cycle, case rate
S4017 Incomplete cycle, treatment cancelled prior to stimulation, case rate
S4018 Frozen embryo transfer procedure cancelled before transfer, case rate
S4020 In vitro fertilization procedure cancelled before aspiration, case rate
S4021 In vitro fertilization procedure cancelled after aspiration, case rate
S4023 Donor egg cycle, incomplete, case rate
S4025 Donor services for in vitro fertilization (sperm or embryo), case rate
S4026 Procurement of donor sperm from sperm  bank
S4027 Storage of previously frozen embryos
S4028 Microsurgical epididymal sperm aspiration (MESA)
S4030 Sperm procurement and cryopreservation services; initial visit
S4031 Sperm procurement and cryopreservation services; subsequent visit
S4040 Monitoring and storage of cryopreserved embryos, per 30 days
0058T Cryopreservation; reproductive tissue, ovarian
0357T Cryopreservation; immature oocyte(s)

Zygote Intra – Fallopian Transfer (ZIFT)

58976 Gamete, zygote, or embryo intrafallopian transfer, any method

S4014 Complete cycle, zygote intrafallopian transfer (ZIFT), case rate Gamete Intra – Fallopian Transfer (GIFT) CPT

S4013 Complete cycle, gamete intrafallopian transfer (GIFT), case rate Cryopreserved Embryo Transfers

S4037 Cryopreserved embryo transfer, case rate
S4018 Frozen embryo transfer procedure cancelled before transfer Intracytoplasmic Sperm Injection (ICSI); or Ovum Microsurgery

89280 Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
89281 Assisted oocyte fertilization, microtechnique; greater than 10 oocytes
55870 Electroejaculation

Unlisted Code

89398 Unlisted reproductive medicine lab procedure

Sterilization Reversal Services
If there is a difference between the information listed in the tables below and the member’s  contract, the member’s contract prevails.

55400 Vasovasostomy, vasovasorrhaphy
58679 Unlisted laparoscopy procedure, oviduct, ovary
58750 Tubotubal anastomosis
58760 Fimbrioplasty
58672 Laparoscopy, surgical; with fimbrioplasty
58673 Laparoscopy, surgical; with salpingostomy (salpingoneostomy)
69990 Microsurgical techniques, requiring use of operating microscope (List separately in  addition to code for primary procedure)

Note :
CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS  codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS)/

Definition of Terms

Impaired fecundity:

A woman is physically able to have a child but is unable to conceive a pregnancy or carry a pregnancy to live birth.


“Not being able to get pregnant (conceive) after one year of unprotected sex.”

Infertility is “ …  the result of a disease (an interruption, cessation, or disorder of body functions,  systems, or organs) of the male or female reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery.

The rates of impaired fecundity and infertility in the United States in 2011 – 2015 of men and  women aged 15 – 44, reported by the National  Center for Health Statistics :
* Infertility rate among married women:  6.7 %
* Impaired fecundity among all women:  12.1 %


A variety of techniques are available to establish a viable pregnancy for couples who have been  diagnosed with infertility and for whom assisted insemination has been unsuccessful.


Infertility can be due either to female factors (ie , pelvic adhesions, ovarian dysfunction,  endometriosis,  or  prior tubal ligation), male factors (ie
, abnormalities in sperm production,  function,  or transport , or prior vasectomy), a combination of both male and female factors, or  other  unknown causes.


Various reproducti ve techniques are available to establish a viable pregnancy; different  techniques are used depending on the reason for infertility.

Assisted reproductive technologies  (ARTs), as defined by the Centers for Disease Control and Prevention (CDC) and other  organizations, refers to fertility treatments in which both the eggs and sperm are handled. Not  included in ART is assisted insemination (artificial insemination) using sperm from either a  woman’s partner or a sperm donor. In most instances, ART will involve in vitro fertilization (IVF),  a procedure in which oocytes harvested from the female are inseminated in vitro with sperm  harvested from the male. Following the fertilization procedure, the zygote is cultured and  ultimately transferred back into the female’s uterus or fallopian tubes. In some instances, the  oocyte and sperm are collected, but no in vitro fertilization takes place, and the gametes are  reintroduced into the fallopian tubes. Examples of ARTs include, but are not limited to, gamete  intrafallopian transfer (GIFT), transuterine fallopian transfer (TUFT), natural oocyte retrieval with  intravaginal fertilization (NORIF), pronuclear state tubal transfer (PROST), tubal embryo transfer
(TET), zygote intrafallopian transfer (ZIFT), gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy.

The various components of ART and implantation into the uterus can be broadly subdivided into oocyte harvesting procedures, which are performed on the female partner; sperm collection  procedures, which are performed on the male partner ; and the in vitro component,  ( ie, the  laboratory procedures ) , which are performed on the collected oocyte and sperm. The final step  is the implantation procedure.