Harvard Pilgrim is updating our prior authorization medical review criteria for infertility services in Massachusetts and Connecticut to include guidelines for single embryo transfers (SET) for in vitro fertilization (IVF). Effective for prior authorizations received as of January 15, 2017, the following criteria also apply for IVF services:
- Members under age 35 are required to have SET during the first two IVF treatment cycles with more than one top-quality embryo available for transfer.
- Members age 35 to 38 are required to have SET for the first IVF cycle if there is more than one top-quality embryo available for transfer from a fresh cycle or 1 top-quality frozen embryo after thawing.
- Members under age 38 with a documented live birth from IVF treatment are required to have SET for one treatment/cycle if there are more than one top-quality embryos available from a fresh cycle, or 1 top-quality frozen embryo after thawing.
- Members age 38 or older undergoing authorized IVF cycles are not required to undergo SET as the risk for multiples is low.
For complete information, please refer to the updated Prior Authorization Medical Review Criteria for Infertility Services — Massachusetts and Prior Authorization Medical Review Criteria for Infertility Services — Connecticut.