Does S4030 require prior authorization?

No, S4030 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S4030?

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

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`S4030`, Sperm procurement and cryopreservation services; initial visit

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

Cross-reference: criteria related to cryopreservation are addressed in CP.MP.55 Assisted Reproductive Technologies (see that policy for cryopreservation requirements).
For individuals with a female reproductive system aged ≥40 requesting retrieval of their own oocytes, documentation that the treating provider has evaluated: age, infertility risk factors, and a measure of ovarian reserve, and that the provider considers use of the member's own oocytes a viable strategy for attempting future conception.

Clinical documentation supporting the diagnosis and planned gonadotoxic or fertility-threatening therapy (as referenced by policy sections I and III stating the treatment causing risk must be medically necessary).

Key Coverage Criteria

Patients undergoing bilateral oophorectomy with risk of loss of fertility.
Patients receiving gonadotoxic therapy (e.g., alkylating agents) with risk of infertility.
Patients receiving cytotoxic chemotherapy that may impair future fertility.
Patients receiving radiation therapy with potential gonadal exposure risking fertility loss.
Patients with other iatrogenic causes that may transiently or permanently affect fertility.
Ovarian stimulation and retrieval of oocytes for adults and adolescents with a female reproductive system prior to commencing medically necessary treatment likely to cause infertility (excluding voluntary sterilization).

5 Active Policies

AMBETTER-CP.MP.130, Fertility Preservation

BCBSIL-OB402.023, Reproductive Techniques and Immunotherapy for Recurrent Fetal Loss

BCBSMT-OB402.023, Reproductive Techniques and Immunotherapy for Recurrent Fetal Loss

BCBSNM-OB402.023, Reproductive Techniques and Immunotherapy for Recurrent Fetal Loss

BCBSOK-OB402.023, Reproductive Techniques and Immunotherapy for Recurrent Fetal Loss

`S4030`, Sperm procurement and cryopreservation services; initial visit

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

S4030, Sperm procurement and cryopreservation services; initial visit

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`S4030`, Sperm procurement and cryopreservation services; initial visit