TL;DR: Aetna, a CVS Health company, modified CPB 1082 governing follitropin and menotropin coverage policy, effective December 4, 2025. If your practice bills HCPCS codes S0122, S0126, or S0128 for injectable fertility drugs, here's what your billing team needs to know.
Aetna updated CPB 1082 to refine medical necessity criteria for follitropins (Gonal-F, Follistim AQ) and menotropins (Menopur) under commercial plans. The policy sets specific step-therapy and clinical thresholds that determine whether S0126 (follitropin alfa), S0128 (follitropin beta), or S0122 (menotropins) will clear precertification. If your team hasn't reviewed the updated criteria against your patient mix, claim denial exposure is real.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Follitropins and Menotropins |
| Policy Code | CPB 1082 |
| Change Type | Modified |
| Effective Date | December 4, 2025 |
| Impact Level | High |
| Specialties Affected | Reproductive Endocrinology, OB/GYN, Urology, Fertility Clinics |
| Key Action | Audit precertification workflows for S0122, S0126, and S0128 against updated step-therapy and age criteria before billing |
Aetna Follitropin and Menotropin Coverage Criteria and Medical Necessity Requirements 2025
The updated Aetna follitropin and menotropin coverage policy draws a clear line: these drugs are not first-line. Medical necessity approval requires patients to have failed, or have a documented reason to skip, earlier-line oral agents.
Follicle Stimulation (ART and Ovulation Induction)
For follitropins (S0126 for follitropin alfa, S0128 for follitropin beta) and menotropins (S0122), Aetna requires that at least one of the following conditions is met before approving follicle stimulation:
| # | Covered Indication |
|---|---|
| 1 | The member completed three or more prior cycles of clomiphene or letrozole |
| 2 | The member has a documented risk factor for poor ovarian response to clomiphene or letrozole |
| 3 | The member has a contraindication or exclusion to clomiphene or letrozole |
| 4 | The member is 37 years of age or older |
The age threshold matters. A patient who is 37 or older qualifies without a prior clomiphene or letrozole trial. Make sure your precertification requests include the date of birth — reviewers will check it.
Hypogonadotropic Hypogonadism (Follitropins Only)
Follitropins — but not menotropins — are also covered for hypogonadotropic hypogonadism treatment. This indication requires both conditions to be met:
| # | Covered Indication |
|---|---|
| 1 | Low pretreatment testosterone levels |
| 2 | Low or low-normal FSH or LH levels |
Both lab values must be documented. Missing one means the request fails medical necessity on this pathway. Pull the actual lab results before submitting, not just a clinical note that says "low testosterone."
Prior Authorization Requirements
Precertification is required for Follistim AQ, Gonal-F, Gonal-F RFF, and Menopur for all Aetna participating providers and members on applicable plan designs. Call (866) 782-2779 or fax (860) 754-2515.
There is a bypass option worth knowing. If the infertility procedure itself — such as an ART cycle — has already been approved under the member's Aetna medical benefit, specialty pharmacy medical necessity review for the associated infertility drugs may be bypassed. You'll need the medical authorization number from the procedure approval to use this pathway. Some plans opt out of the bypass entirely and require full drug review regardless. Check the plan documents before assuming the bypass applies.
Continuation of Therapy
Reauthorization follows the same criteria as initial approval. Members requesting continuation — including new members who transfer mid-cycle — must meet all initial authorization criteria at the time of reauthorization. There is no grandfathering for patients already on therapy.
Aetna Follitropin and Menotropin Exclusions and Non-Covered Indications
Aetna treats all other indications for follitropins and menotropins as experimental, investigational, or unproven. The policy is explicit: if the indication doesn't fit follicle stimulation for ART or ovulation induction, or hypogonadotropic hypogonadism for follitropins, it doesn't get covered.
Two CPT codes appear in the policy with specific non-coverage notes. CPT 58974 (embryo transfer, intrauterine) and CPT 89255 (preparation of embryo for transfer) are not covered when the sole purpose is endometrium preparation for frozen embryo transfer. These codes are listed under "other CPT codes related to the CPB" — Aetna is signaling that billing these procedures purely for endometrial prep on a frozen cycle won't fly.
The real trap here is plan-level variation. Many plans exclude infertility injectable medications outright. Others cap ovulation induction cycles with menotropins at a specific lifetime limit. This coverage policy sets the floor, but the member's plan document may be more restrictive. Check the plan before you assume the policy criteria alone control the outcome.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Follicle stimulation (ART or ovulation induction) — ≥3 prior clomiphene/letrozole cycles | Covered | S0122, S0126, S0128 | Prior auth required; precertification via (866) 782-2779 |
| Follicle stimulation (ART or ovulation induction) — risk factor for poor ovarian response | Covered | S0122, S0126, S0128 | Document clinical risk factor in precert request |
| Follicle stimulation (ART or ovulation induction) — contraindication/exclusion to clomiphene or letrozole | Covered | S0122, S0126, S0128 | Contraindication must be documented in chart |
| Follicle stimulation (ART or ovulation induction) — member age 37 or older | Covered | S0122, S0126, S0128 | Age alone qualifies; no prior trial required |
| Hypogonadotropic hypogonadism — low testosterone AND low/low-normal FSH or LH | Covered | S0126, S0128 | Follitropins only; menotropins not covered for this indication |
| All other follitropin/menotropin indications | Experimental / Not Covered | S0122, S0126, S0128 | Treated as experimental, investigational, or unproven |
| Embryo transfer (CPT 58974) — solely for endometrium prep for frozen embryo transfer | Not Covered | 58974 | Plan documents may vary |
| Embryo prep (CPT 89255) — solely for endometrium prep for frozen embryo transfer | Not Covered | 89255 | Plan documents may vary |
Aetna Follitropin and Menotropin Billing Guidelines and Action Items 2025
The updated policy took effect December 4, 2025. If your team hasn't adjusted workflows yet, act now.
| # | Action Item |
|---|---|
| 1 | Audit your precertification templates for S0122, S0126, and S0128. Each request must document which qualifying criterion the patient meets — prior clomiphene/letrozole cycles, documented risk factor, contraindication, or age. Generic "infertility" language won't pass review. Update your templates before the next submission cycle. |
| 2 | Build an age-flag into your intake workflow. Patients who are 37 or older qualify for follicle stimulation coverage without completing oral agent trials. If your intake process doesn't capture date of birth before precertification, you're creating unnecessary step-therapy documentation burdens for patients who don't need it. |
| 3 | Separate your follitropin and menotropin requests for hypogonadism cases. Menotropins (S0122) are not covered for hypogonadotropic hypogonadism. Only follitropins (S0126, S0128) qualify. Billing S0122 for a hypogonadism indication will generate a claim denial. Make sure your coding team knows which drug maps to which pathway. |
| 4 | Check the ART procedure bypass before routing through specialty pharmacy. If your team secured medical plan approval for an ART procedure, get that authorization number and use the bypass pathway for associated drug coverage. It saves time and reduces duplicative review. Confirm first whether the member's plan opts out of the bypass — some plans require full drug review regardless. |
| 5 | Pull and document lab values before submitting hypogonadism requests. Aetna requires both low testosterone and low or low-normal FSH or LH to meet medical necessity on the hypogonadism pathway. A clinical note alone won't be enough. Attach the actual lab results to the precertification submission. |
| 6 | Review plan documents for every infertility patient. The CPB 1082 coverage policy sets the payer-level criteria, but individual plan exclusions can override it. Infertility injectable medications are excluded outright in many plans, and others cap lifetime menotropin cycles. Verify the specific plan before telling a patient their drugs will be covered. |
| 7 | Update your reauthorization criteria checklist. Continuation requests must meet all initial criteria — there is no grace period for patients already on therapy. If a patient no longer meets the documented basis for initial approval, the reauthorization won't clear. Build a standing checklist your clinical team completes before each reauth request. |
If your practice is in a high-volume reproductive endocrinology or fertility setting and you're billing S0122, S0126, or S0128 at scale, loop in your compliance officer to confirm your precertification workflows fully reflect the December 4, 2025 effective date changes.
| 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 Follitropins and Menotropins Under CPB 1082
HCPCS Codes Covered When Selection Criteria Are Met
| Code | Type | Description |
|---|---|---|
| S0122 | HCPCS | Injection, menotropins, 75 IU |
| S0126 | HCPCS | Injection, follitropin alfa, 75 IU |
| S0128 | HCPCS | Injection, follitropin beta, 75 IU |
Other CPT Codes Related to CPB 1082 (Non-Covered for Specific Indications)
| Code | Type | Description | Non-Coverage Note |
|---|---|---|---|
| 58974 | CPT | Embryo transfer, intrauterine | Not covered solely for endometrium preparation for frozen embryo transfer |
| 89255 | CPT | Preparation of embryo for transfer (any method) | Not covered solely for endometrium preparation for frozen embryo transfer |
Note on ICD-10 codes: CPB 1082 does not list specific ICD-10-CM diagnosis codes. Diagnosis coding for follitropin and menotropin claims should reflect the documented clinical indication — ovulatory dysfunction, hypogonadotropic hypogonadism, infertility — as supported by the patient's chart. Work with your medical director to confirm appropriate diagnosis coding aligns with the indication category Aetna approved in precertification.
Get the Full Picture for CPT 58974
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.