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Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective November 17, 2005 (Posted September 15, 2005)

Medical Policy Revision
Infertility, Diagnosis and Treatment Description section revised. Note: The following are dependant on the individual certificate language re: infertility and IVF: Under "When Covered" section: A.2.- Diagnostic tests for the Male/ Semen analysis - testicular biopsy listed as a separate entity, not as part of semen analysis; sperm penetration assay added as medically necessary to determine whether ICSI should be offered as part of an IVF technique. Under "When not Covered" section: B. Diagnostic tests/sperm penetration assay moved to covered section; assessment of sperm movements-added computer assisted sperm analysis (CASA) to the end of the statement; assessments of the ability of sperm to interact with heterologous or homologous oocytes removed; Hyaluronan binding assay (HBA) added as investigational; D. Assisted Reproductive Technologies/AI/Contraindications in Fe-tubal obstruction listed as a separate bullet; endometriosis listed as a separate bullet and revised to "severe endometriosis (Stage IV)"; D.3. added thawing; D.4. now reads: "Charges related to the testing and transport fees or any other charges incurred due to cryopreservation, storage and thawing of sperm/ semen and testicular tissue are not covered under standard medical benefits or under infertility benefits unless otherwise stated in the individual certificate."; added D.7."Charges related to co-culture of embryos are considered investigational and are not covered; added D.8.-"Charges related to cryopreservation, storage and thawing of ovarian tissue or oocytes are considered investigational and are not covered." Reference sources and medical term definitions added. Specialty Matched Consultant Advisory Panel (CAP) review 8/25/05. Based on CAP recommendations, under When Covered section: A.1.- Diagnostic tests for the Female, added fasting insulin and serum Chlamydia IgG. Notification given 9/15/05. Effective date 11/17/05.