Covered without prior authorization (high confidence)
Documentation Required
Refills based upon documentation in cycle sheets.
Benefit plan documentation: because "Some plans exclude infertility services for ovarian failure; please check benefit plan descriptions," documentation of plan-specific coverage determinations may be required.
Semen analysis documentation: severe semen quantity or quality deficits require documentation on 2 separate occasions at least 2 weeks apart.
For use of gonadotropin therapy in males (hypogonadotropic hypogonadism), documentation of normalization of serum testosterone levels is required prior to administration of recombinant follitropin for induction of spermatogenesis (policy text: "after normal serum testosterone levels are reached").
Key Coverage Criteria
N98.1: Hyperstimulation of ovaries
N99.83: Residual ovary syndrome
Benign neoplasm and neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct (D35.2 - D35.3; D44.3 - D44.4)
Neoplasm of uncertain behavior of female genital organs (D39.0 - D39.2)
Neoplasm of uncertain behavior of other and unspecified male genital organs (D40.8 - D40.9)
Iodine-deficiency related thyroid disorders and allied conditions (E01.8), subclinical iodine-deficiency hypothyroidism (E02), other hypothyroidism (E03.0 - E03.8)
Documentation of prior responses to gonadotropin stimulation should be used to individualize initial dosing in subsequent cycles (policy text: initial dose in subsequent cycles is individualized based on prior response).
Check benefit plan descriptions for exclusions (plans may exclude infertility services for ovarian failure).