CommercialPrior AuthHigh impact
Human Chorionic Gonadotropin (hCG) (CPB 1081, reviewed 12-2025-08)
Aetna·OB-GYN, Endocrinology, Urology +3 more·Medical Policy
Effective date
Dec 8, 2025
We identified it
Aug 15, 2026
Summary
Aetna updated its hCG (Human Chorionic Gonadotropin) clinical policy (CPB 1081) effective December 2025. Key coverage remains for ART/ovulation induction, cryptorchidism, hypogonadotropic hypogonadism, and acute GVHD, but the policy explicitly excludes coverage for hCG used solely for endometrium preparation in frozen embryo transfer (FET). Precertification is required for all hCG products (Novarel, Pregnyl, Ovidrel, generics), and specialty pharmacy medical necessity review may be bypassed if the underlying infertility procedure is pre-approved.
Action Required
By December 8, 2025: (1) Billing team must implement precertification requirement for all hCG claims—update billing software to require prior authorization submission to Aetna at (866) 782-2779 or fax (860) 754-2515 before claim submission; (2) Update claim denial logic to reject hCG claims for obesity/weight loss management (ICD-10 E66.01-E66.9, Z68.1-Z68.56) and for FET endometrium preparation alone (CPT 58974, 89255); (3) For infertility claims, obtain confirmation that the underlying ART procedure (e.g., IVF) is approved before bypassing specialty pharmacy medical necessity review—document authorization number on claim; (4) Providers must be notified that some plans require specialty pharmacy review of ALL infertility drugs regardless of procedure approval; (5) Coding staff must distinguish between covered indications (ART, ovulation induction, cryptorchidism, hypogonadism meeting criteria, GVHD) and non-covered/experimental uses; (6) Configure system to flag claims for idiopathic male infertility, idiopathic microphallus, and FET endometrium preparation as experimental/non-covered. Failure to obtain precertification will result in claim denials.