Aetna modified CPB 0327, its infertility coverage policy, effective December 20, 2025. Here's what billing teams need to know before submitting claims.
Aetna, a CVS Health company, updated Clinical Policy Bulletin 0327 governing infertility services across commercial medical plans. This policy touches a massive code set — 501 CPT codes, 89 HCPCS codes, and 523 ICD-10-CM diagnosis codes — covering everything from intrauterine insemination (CPT 58322) and sperm washing (CPT 58323) to laparoscopic myomectomy (CPT 58545–58546), hysteroscopy (CPT 58555–58563), and advanced reproductive technology (ART) procedures. If your practice bills infertility services to Aetna commercial plans, this update affects your charge capture, your prior authorization workflow, and your drug benefit alignment process.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Infertility — CPB 0327 |
| Policy Code | CPB 0327 |
| Change Type | Modified |
| Effective Date | December 20, 2025 |
| Impact Level | High |
| Specialties Affected | Reproductive endocrinology, urology, OB/GYN, general surgery, clinical laboratory |
| Key Action | Audit your precertification workflow for ART drugs and procedures before billing against this updated policy |
Aetna Infertility Coverage Criteria and Medical Necessity Requirements 2025
The CPB 0327 Aetna infertility coverage policy adopts the ASRM's 2023 definition of infertility. That definition is broader than what many billing teams are used to seeing in payer policy language.
Under this definition, infertility includes the inability to achieve pregnancy based on medical history, age, physical findings, or diagnostic testing. It also includes patients who need donor gametes or embryos. Critically, the definition explicitly states that nothing in it "shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation."
That language matters for your claim submissions. Denials based on relationship status or sexual orientation are inconsistent with this policy. Document that clearly in your appeals workflow.
Medical Necessity Thresholds by Age
Two distinct requirements govern when ART is appropriate. The first applies to patients without a known etiology. For those patients, Aetna uses an age-based threshold to determine when evaluation should begin: 12 months of regular unprotected intercourse for women under 35, and six months for women 35 and older.
The second requirement is ART-specific. For plans that include an ART benefit, the policy requires a documented trial of egg-sperm contact before ART procedures are authorized. For women under 35, that means four cycles of timed intrauterine or intracervical inseminations (CPT 58322 for IUI, CPT 58321 for intracervical) or 12 months of regular intravaginal inseminations. For women 35 and older, it means four cycles of timed inseminations or six months of regular intravaginal inseminations. These are separate but related thresholds — don't conflate them in your precertification documentation.
Document the trial period clearly in the medical record. If you're billing CPT 58322 (intrauterine insemination) or CPT 58323 (sperm washing) as part of that required trial, that documentation supports both current claims and future ART authorization requests.
Prior Authorization Requirements
Precertification is required for a specific list of fertility drugs. Those drugs include:
| # | Covered Indication |
|---|---|
| 1 | Cetrotide (cetrorelix acetate) |
| 2 | Ganirelix acetate |
| 3 | Follistim AQ (follitropin beta) |
| 4 | Gonal-F (follitropin alfa) |
| 5 | Menopur (menotropins) |
| 6 | Novarel and Pregnyl (chorionic gonadotropin) |
| 7 | Ovidrel (choriogonadotropin alfa) |
Call (866) 782-2779 or fax (860) 754-2515 for precertification. Use the Specialty Pharmacy Precertification SMN forms from Aetna's provider portal.
The prior authorization requirements for ART drugs include an important bypass option. If the infertility procedure itself has already been approved under the member's Aetna medical benefit plan, Specialty Pharmacy Guideline Management review of the associated ART drugs can be bypassed. You'll need the medical authorization number from the procedure approval to use that bypass.
Some plans require Specialty Pharmacy Guideline Management review of all infertility drugs regardless. Check the member's specific plan before assuming the bypass applies. A missed step here is a direct path to reimbursement delays and claim denial.
Aetna Infertility Exclusions and Non-Covered Indications
The CPB 0327 Aetna infertility coverage policy ties all coverage to medical necessity criteria and plan benefit design. Coverage is not universal across all commercial plans.
Plans without an ART benefit do not cover ART procedures under this policy — regardless of medical necessity. Check the member's benefit plan description before scheduling ART services. Billing ART procedures on a plan without that benefit will produce denials regardless of clinical documentation.
Less invasive approaches must be tried before more invasive ones for plans that do include an ART benefit. The policy is explicit: therapeutic options should proceed in order of invasiveness, directed by a licensed specialist. Jumping straight to IVF without documenting the required trial cycles creates medical necessity risk on every claim.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Intrauterine insemination (IUI) | Covered if criteria met | CPT 58322, 58323 | Requires documented trial per age threshold |
| Intracervical insemination | Covered if criteria met | CPT 58321 | Part of required egg-sperm contact trial |
| Diagnostic hysteroscopy | Covered if criteria met | CPT 58555 | Surgical hysteroscopy variants also covered (58558–58563) |
| Laparoscopic myomectomy | Covered if criteria met | CPT 58545, 58546 | Open approach also covered (58140, 58145, 58146) |
| Endometrial sampling/biopsy | Covered if criteria met | CPT 58100 | With or without endocervical sampling |
| Adhesion lysis (salpingolysis, ovariolysis) | Covered if criteria met | CPT 58660, 58740 | Both laparoscopic and open approaches |
| Tubotubal anastomosis / tubal repair | Covered if criteria met | CPT 58750, 58752, 58760, 58770 | For tubal factor infertility |
| Salpingectomy | Covered if criteria met | CPT 58700, 58720 | Including laparoscopic approach (58661) |
| Male factor — testicular biopsy | Covered if criteria met | CPT 54500, 54505 | Needle and incisional |
| Male factor — vasovasostomy | Covered if criteria met | CPT 55400 | Vasovasorrhaphy included |
| Male factor — epididymovasostomy | Covered if criteria met | CPT 54900, 54901 | Unilateral and bilateral |
| Male factor — varicocele excision | Covered if criteria met | CPT 55530, 55535, 55540 | Abdominal approach and with hernia repair |
| Male factor — electroejaculation | Covered if criteria met | CPT 55870 | For ejaculatory dysfunction |
| Ovarian cyst drainage/excision | Covered if criteria met | CPT 49322, 58800, 58805 | Laparoscopic and open |
| Endometrioma excision | Covered if criteria met | CPT 49203–49205, 49186–49190 | Intra-abdominal, size-stratified codes |
| ART drug precertification (listed agents) | Requires prior auth | HCPCS drug codes | See drug list above; bypass possible if procedure pre-approved |
| ART procedures (IVF, etc.) | Covered if ART benefit exists and criteria met | Per plan benefit | Plans without ART benefit: not covered |
| Infertility services — no ART benefit plan | Not covered | All ART CPT codes | Plan benefit check required before scheduling |
Aetna Infertility Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Verify ART benefit status before scheduling. Pull the member's benefit plan document and confirm whether an ART benefit exists. Do this before the patient's first infertility consultation. Billing ART procedures on a non-ART plan produces automatic denials. |
| 2 | Confirm the drug-procedure bypass before submitting pharmacy claims. If you've already received procedure authorization, get the medical authorization number and use it to bypass Specialty Pharmacy Guideline Management review for associated ART drugs. Missing this step sends drug claims through a slower review process — and some will deny, creating reimbursement delays that are entirely avoidable. |
| 3 | Document the trial period in the medical record now. For every patient who may eventually need ART, start documenting the egg-sperm contact trial from day one. Log dates of IUI cycles (CPT 58322), intracervical inseminations (CPT 58321), and intravaginal inseminations. You'll need this to support ART prior authorization later. |
| 4 | Update your age-based criteria triggers. Your intake workflow should flag the patient's age at first visit. Under-35 patients need a 12-month trial. Patients 35 and older need six months. Build this into your precertification checklist so you're requesting ART authorization at the right time — not early (which gets denied) and not late (which delays treatment and reimbursement). |
| 5 | Audit your charge capture for the male factor codes. CPT 54500, 54505, 54900, 54901, 55400, 55530, 55535, and 55870 are all covered under this policy when criteria are met. Urology practices billing these codes for infertility indications should confirm they're being submitted with supporting ICD-10 documentation. Male factor infertility billing often gets under-documented compared to female factor claims. |
| 6 | Check the hysteroscopy and laparoscopy code range. CPT 58555 through 58563 (hysteroscopy variants) and CPT 58660 through 58673 (laparoscopic adnexal procedures) are all on the covered list. Verify your charge capture maps the correct add-on codes when procedures are combined. |
| 7 | Talk to your compliance officer if your patient mix includes same-sex couples or single individuals. The ASRM definition adopted by this policy explicitly prohibits using relationship status or sexual orientation to deny treatment. But plan-level benefit design can still create coverage gaps. Your compliance officer should review how your specific contracted plans handle this before the effective date of December 20, 2025. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Infertility Services Under CPB 0327
Covered CPT Codes (When Selection Criteria Are Met)
This policy covers 501 CPT codes. Below are the key codes relevant to most infertility billing teams. Reference the full CPB 0327 Aetna policy at the source for the complete list.
| Code | Type | Description |
|---|---|---|
| 0167U | CPT | hCG immunoassay with direct optical observation, blood |
| 0353U | CPT | Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acid detection |
| 49186 | CPT | Excision/destruction, open, intra-abdominal (peritoneal, mesenteric, retroperitoneal), primary, up to 5.0 cm |
| 49187 | CPT | 5.1 to 10 cm |
| 49188 | CPT | 10.1 to 20 cm |
| 49189 | CPT | 20.1 to 30 cm |
| 49190 | CPT | Greater than 30 cm |
| 49203 | CPT | Excision/destruction, open, intra-abdominal tumors/cysts/endometriomas, 1 or more peritoneal implants |
| 49204 | CPT | Largest tumor 5.1–10.0 cm |
| 49205 | CPT | Largest tumor greater than 10.0 cm |
| 49320 | CPT | Laparoscopy, abdomen, peritoneum, and omentum, diagnostic |
| 49321 | CPT | Laparoscopy, surgical; with biopsy |
| 49322 | CPT | Laparoscopy with aspiration of cavity or cyst (e.g., ovarian cyst) |
| 52402 | CPT | Cystourethroscopy with transurethral resection or incision of ejaculatory ducts |
| 54500 | CPT | Biopsy of testis, needle |
| 54505 | CPT | Biopsy of testis, incisional |
| 54640 | CPT | Orchiopexy, inguinal approach, with or without hernia repair |
| 54650 | CPT | Orchiopexy, abdominal approach, for intra-abdominal testis |
| 54692 | CPT | Laparoscopy, surgical; orchiopexy for intra-abdominal testis |
| 54800 | CPT | Biopsy of epididymis, needle |
| 54830 | CPT | Excision of local lesion of epididymis |
| 54840 | CPT | Excision of spermatocele, with or without epididymectomy |
| 54860 | CPT | Epididymectomy, unilateral |
| 54861 | CPT | Epididymectomy, bilateral |
| 54865 | CPT | Exploration of epididymis, with or without biopsy |
| 54900 | CPT | Epididymovasostomy, unilateral |
| 54901 | CPT | Epididymovasostomy, bilateral |
| 55000 | CPT | Puncture aspiration of hydrocele, tunica vaginalis |
| 55040 | CPT | Excision of hydrocele, unilateral |
| 55041 | CPT | Excision of hydrocele, bilateral |
| 55060 | CPT | Repair of tunica vaginalis hydrocele (Bottle type) |
| 55110 | CPT | Scrotal exploration |
| 55300 | CPT | Vasotomy for vasograms, seminal vesiculograms, or epididymograms |
| 55400 | CPT | Vasovasostomy, vasovasorrhaphy |
| 55500 | CPT | Excision of hydrocele of spermatic cord, unilateral |
| 55530 | CPT | Excision of varicocele or ligation of spermatic veins (separate procedure) |
| 55535 | CPT | Varicocele excision, abdominal approach |
| 55540 | CPT | Varicocele excision with hernia repair |
| 55870 | CPT | Electroejaculation |
| 57530 | CPT | Trachelectomy (cervicectomy), amputation of cervix |
| 58100 | CPT | Endometrial sampling (biopsy) with or without endocervical sampling |
| 58120 | CPT | Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) |
| 58140 | CPT | Myomectomy, 1 to 4 intramural myomas, total weight ≤250 g |
| 58145 | CPT | Myomectomy, vaginal approach |
| 58146 | CPT | Myomectomy, 5 or more intramural myomas and/or total weight >250 g |
| 58321 | CPT | Artificial insemination, intracervical |
| 58322 | CPT | Artificial insemination, intrauterine |
| 58323 | CPT | Sperm washing for artificial insemination |
| 58340 | CPT | Catheterization and introduction of saline or contrast for saline infusion sonohysterography |
| 58345 | CPT | Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency |
| 58350 | CPT | Chromotubation of oviduct, including materials |
| 58545 | CPT | Laparoscopy, surgical, myomectomy; 1 to 4 intramural myomas, total weight ≤250 g |
| 58546 | CPT | Laparoscopy, surgical, myomectomy; 5 or more intramural myomas and/or total weight >250 g |
| 58555 | CPT | Hysteroscopy, diagnostic (separate procedure) |
| 58558 | CPT | Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C |
| 58559 | CPT | Hysteroscopy with lysis of intrauterine adhesions |
| 58560 | CPT | Hysteroscopy with division or resection of intrauterine septum |
| 58561 | CPT | Hysteroscopy with removal of leiomyomata |
| 58562 | CPT | Hysteroscopy with removal of impacted foreign body |
| 58563 | CPT | Hysteroscopy with endometrial ablation |
| 58600 | CPT | Ligation or transection of fallopian tube(s) |
| 58660 | CPT | Laparoscopy with lysis of adhesions (salpingolysis, ovariolysis) |
| 58661 | CPT | Laparoscopy with removal of adnexal structures |
| 58662 | CPT | Laparoscopy with fulguration or excision of lesions of ovary, pelvic viscera, or peritoneal surface |
| 58672 | CPT | Laparoscopy with fimbrioplasty |
| 58673 | CPT | Laparoscopy with salpingostomy (salpingoneostomy) |
| 58700 | CPT | Salpingectomy, complete or partial, unilateral or bilateral |
| 58720 | CPT | Salpingo-oophorectomy, complete or partial, unilateral or bilateral |
| 58740 | CPT | Lysis of adhesions (salpingolysis, ovariolysis) |
| 58750 | CPT | Tubotubal anastomosis |
| 58752 | CPT | Tubouterine implantation |
| 58760 | CPT | Fimbrioplasty |
| 58770 | CPT | Salpingostomy (salpingoneostomy) |
| 58800 | CPT | Drainage of ovarian cyst(s), vaginal approach |
| 58805 | CPT | Drainage of ovarian cyst(s), abdominal approach |
| 58820 | CPT | Drainage of ovarian abscess, vaginal approach, open |
| 58822 | CPT | Drainage of ovarian abscess, abdominal approach |
| 58825 | CPT | Transposition, ovary(s) |
| 58900 | CPT | Biopsy of ovary, unilateral or bilateral |
| 58920 | CPT | Wedge resection or bisection of ovary, unilateral or bilateral |
421 additional CPT codes are listed in the full CPB 0327 policy. Access the complete code set at the Aetna CPB 0327 source document.
HCPCS Codes
The policy includes 89 HCPCS codes covering infertility-related drugs and biologicals. The precertification-required drugs — cetrorelix acetate, ganirelix acetate, follitropin beta, follitropin alfa, menotropins, chorionic gonadotropin, and choriogonadotropin alfa — each carry HCPCS codes subject to Specialty Pharmacy Guideline Management review. Access the full HCPCS code list in the CPB 0327 Aetna system entry at PayerPolicy.
Key ICD-10-CM Diagnosis Codes
The policy maps to 523 ICD-10-CM codes. The full diagnosis code list is available in the CPB 0327 source policy. Your coding team should cross-reference these codes when documenting infertility diagnoses to support medical necessity for covered procedures. Diagnosis codes for male factor infertility, ovulatory dysfunction, tubal disease, endometriosis, and uterine structural anomalies are all represented in the mapped set.
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