The Plan covers the diagnosing and treatment of infertility as well as treatment needed to conceive, including covered artificial insemination procedures. Infertility may also be established through an evaluation based on medical history and diagnostic testing.
Artificial means of conception includes any means of attempting pregnancy that does not involve coitus. The Plan considers artificial insemination (intra-cervical insemination, intra-uterine insemination, or intra-vaginal insemination) to be medically necessary for the treatment of infertility for any of the following:
-
infertile couples with mild male-factor fertility problems;
-
unexplained infertility problems;
-
minimal to mild endometriosis;
-
medically refractory erectile dysfunction or vaginismus preventing intercourse;
-
couples where the man is HIV positive and undergoing sperm washing;
-
couples undergoing menotropin ovarian stimulation; or clomiphene-citrate-stimulated artificial insemination (intra-cervical insemination or IUI) medically necessary for infertile women with WHO Group II ovulation disorders such as polycystic ovarian syndrome who ovulate with clomiphene citrate but have not become pregnant after ovulation induction with clomiphene.
Prior to the initiation of Artificial Insemination, the member must complete an evaluation of the:
-
ovulatory disorders
-
tubal abnormalities
-
cervical abnormalities
-
immunologic factors
