Medicaid Coverage of Fertility Preservation Services for Iatrogenic Infertility, Effective October 7, 2023

By November 20, 2023: Billing team must implement prior authorization requirements for all fertility preservation services billed to Maryland Medicaid. Update billing system to require pre-auth before processing claims for CPT/HCPCS codes 58825, 55870, 58970, 76948, 89254, 89257, 89259, 89264, 89337, 89398, S0132, S4028, S4042, J0725, J3355, S0122, S0126, and S0128. Ensure providers (reproductive endocrinologists only) submit prior authorization requests with: (1) documentation of iatrogenic infertility diagnosis, (2) treatment plan showing medical necessity, (3) patient age confirmation (puberty to menopause, except prepubertal ovarian tissue cases), and (4) parental consent if patient is a minor. Set system to authorize procedures for 3-month periods maximum. Limit oocyte/sperm cryopreservation to one-time benefit with maximum 3 cycles of ovarian stimulation. Configure billing system to reject claims for non-covered services (donor gametes, IVF, intrauterine insemination, storage/thawing, prepubertal testicular tissue). Update fee schedules with new reimbursement rates per Table 1. Notify reproductive endocrinology providers of new coverage, prior authorization process, and clinical criteria. Claims submitted without prior authorization will be denied.