Aetna IVF coverage policy: step therapy, PGT-A, and what gets denied (2026)
Policy: Clinical Policy Bulletin 0327 — Infertility. This is the clinical policy your clinic's authorization team is arguing against. Knowing it before you start avoids the most common denials.
Step therapy (IUI before IVF)
Required. Requires a trial of ovulation induction / intrauterine insemination (typically 6–12 months or a defined number of IUI cycles) before IVF unless a bypass indication is documented.
Bypass criteria:
- Age 38 or older
- Bilateral tubal factor / tubal occlusion
- Stage III–IV endometriosis
- Severe male factor infertility
- Prior failed IUI cycles per policy count
Ovarian reserve and age thresholds
- Day-3 FSH below 19 mIU/mL required for coverage of stimulation cycles
Considered experimental / not medically necessary
- PGT-A for IVF optimization (without a hereditary-disease indication)
- Endometrial receptivity analysis (ERA)
- ICSI without male-factor diagnosis
- Sperm DNA fragmentation testing
Prior authorization required for
- Each IVF cycle
- Medications via specialty pharmacy
- FET
Billing quirks that cause denials
- Ultrasound guidance (76948) bundled into retrieval
- Uses HCPCS S-code mapping tool for global IVF billing
Appeal tips
- If age 38+ or a bypass diagnosis applies, cite the specific CPB 0327 bypass language and attach the diagnosis documentation.
- For PGT-A denials, expect 'experimental' — external review is possible on medical-judgment grounds, but success is limited; consider whether the clinic can document a hereditary indication.
- Request the specific policy section relied upon in the denial letter (ACA requires disclosure).