Does S4028 require prior authorization?

No, S4028 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S4028?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S4028`, Microsurgical epididymal sperm aspiration (mesa)

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Refer to pharmacy policy CP.PHAR.131 for prior authorization and documentation requirements for FDA‑approved infertility medications.
Record verifying treating physician's board certification or board-eligible status in reproductive endocrinology (or urology for male reproductive system).

Clinical documentation showing inability to conceive after required period of cycles exposed to sperm (12 months, or 6 months if female reproductive system age ≥35), including notes regarding prior IUI attempts if applicable.

For members with female reproductive systems ≥40 using their own oocytes: documentation that the treating provider evaluated age, infertility risk factors, a measure of ovarian reserve, prior treatment and response, and concluded that use of the member's own oocytes is a viable strategy for attempting conception.

Key Coverage Criteria

Unexplained infertility in individuals with a female reproductive system aged ≥ 38 years.
Diagnostic infertility services to determine the cause of infertility and guide treatment when the member's benefit plan specifically provides coverage for infertility services.
Coverage may include evaluation and treatment related to a partner's infertility when the member's plan terms allow.
ART services (including handling of oocytes, sperm, or embryos) performed solely for the treatment of infertility when all applicable ART policy criteria are met.
Use of FDA‑approved medications for infertility (including specialty injectables) such as clomiphene, aromatase inhibitors, estrogens, corticosteroids, progestins, metformin, prolactin inhibitors, GnRH agonists/antagonists, and gonadotropins (see pharmacy policy CP.PHAR.131).
ART performed by a physician board-certified or board-eligible in reproductive endocrinology for individuals with a female reproductive system; for those with a male reproductive system, performed by a board-certified or board-eligible urologist or reproductive endocrinologist.

2 Active Policies

AMBETTER-CP.MP.55, Assisted Reproductive Technology

AMBETTER-CP.MP.130, Fertility Preservation

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S4028, Microsurgical epididymal sperm aspiration (mesa)