Cigna IVF coverage policy: step therapy, PGT-A, and what gets denied (2026)
Policy: Cigna Medical Coverage Policy 0089 — Infertility Services (current version effective 2025-06-15; revised version posted 2026-07-15 with effective date 2026-10-15); PGT reviewed under EviCore Lab Management Guideline MOL.CU.119.A Preimplantation Genetic Testing (V1.0.2026, eff. 2026-01-01). 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)
Not a hard requirement. CP 0089 does not impose a hard IUI-before-IVF gate. The only stated prerequisite is a diagnosis: 'In the absence of a diagnosis of infertility, in-vitro fertilization (IVF) services are considered not medically necessary.' Infertility is defined as 'the need for medical intervention to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history; age, physical findings, diagnostic testing, or any combination of those factors' (evaluation 'is reasonable after six months for women over the age of 35 years'; 'For woman over the age of 40 more immediate evaluation and treatment may be considered'). The background section cites ASRM's sequence for unexplained infertility — 'A course of 3-4 cycles of ovarian stimulation/IUI with oral agents, if unsuccessful followed by ovarian stimulation with IVF cycles' — which reviewers may lean on, and many employer plan documents layer their own IUI-first requirement on top of the policy. Delegated fertility vendors (Cigna LifeSource / Carrot / Progyny on some groups) apply their own protocols.
Ovarian reserve and age thresholds
- CP 0089 contains no hard FSH/AMH cutoff for coverage; the background states 'Decreased ovarian function is seen with a level greater than 10–15 IU/L' (day-3 FSH) as a clinical marker, not a denial threshold
- Ovarian reserve testing (AMH, day-3 FSH/estradiol, AFC) is covered for women 'planning treatment with assisted reproductive technologies (e.g., IVF)', women over 35, single ovary, prior poor gonadotropin response, unexplained infertility, or family history of early menopause
- No policy-level upper age limit for autologous IVF; age/prognosis limits, cycle counts and dollar caps come from the employer plan document (third-party guides cite typical lifetime maximums of $15,000–$25,000 or 3 fresh cycles on rider plans)
Considered experimental / not medically necessary
- PGT-A (aneuploidy screening): reviewed by EviCore under MOL.CU.119.A — 'not medically necessary' for de novo aneuploidy screening including maternal age alone, improving IVF success rates, recurrent miscarriage or implantation failure ('routine use of blastocyst biopsy with aneuploidy testing in all infertile patients undergoing IVF treatment cannot be recommended'); CP 0089 background: 'The value of PGD aneuploidy testing as a universal screening test for all IVF patients has not been demonstrated'. PGT-M and PGT-SR are covered when the condition 'is associated with potentially severe disability or has a lethal natural history'
- Endometrial receptivity testing: 'endometrial receptivity testing (e.g., Endometrial Function Test [EFT], integrin testing, Beta-3 integrin test, E-tegrity, endometrial receptivity array [ERA])' — experimental/investigational/unproven
- Assisted embryo hatching outside listed criteria (covered only for 'individuals 38 years of age or older; elevated day-3 FSH; increased zona thickness on microscopy; three or more IVF-attempt failures related to failed implantation')
- ICSI without a listed indication: ICSI covered for 'very low numbers of motile sperm; severe teratospermia; problems with sperm binding to and penetrating the egg; antisperm antibodies of sufficient quality to prevent fertilization; prior or repeated fertilization failure with standard IVF' — routine ICSI for non-male-factor is not medically necessary (ICSI criteria are being revised in the 2026-10-15 version)
- Sperm DNA integrity/fragmentation testing and reactive oxygen species (ROS) testing — unproven in the 2025-06-15 version ('Current methods for evaluating sperm DNA integrity do not reliably predict treatment outcomes'); NOTE: the 2026-10-15 revision 'Added sperm DNA integrity testing as a covered service'
- Sperm viability test (hypo-osmotic swelling) as a diagnostic test
- Time-lapse embryo monitoring/imaging (EmbryoScope, Eeva)
- Cryopreservation of immature oocytes / in vitro maturation; retrieval, cryopreservation and re-transplantation of ovarian or testicular tissue (unless a state fertility-preservation mandate applies)
- Not covered (benefit exclusion rather than experimental): 'donor charges, fees and services, including services associated with donor sperm and donor oocytes; infertility services rendered to a surrogate and surrogate fees'; cryopreservation of 'embryos when not undergoing covered active infertility treatment'; sperm cryopreservation; oocyte cryopreservation other than when no viable sperm is available on retrieval day during a covered fresh IVF cycle
Prior authorization required for
- Each IVF cycle (fresh retrieval) — authorization tied to the specific CPT/HCPCS codes requested
- Each frozen embryo transfer cycle
- ICSI (must document a listed male-factor or prior-fertilization-failure indication)
- Assisted hatching (must meet the age ≥38 / elevated FSH / zona thickness / ≥3 failed implantations criteria)
- PGT-M / PGT-SR embryo biopsy and lab testing (EviCore genetic testing precertification; codes 0552U–0555U on the Master Precertification List)
- Fertility medications (Express Scripts/Accredo specialty PA)
- Surgical sperm retrieval (TESE/MESA) when covered under the rider
Billing quirks that cause denials
- Cigna authorizes ART one cycle at a time and the authorization is issued against specific procedure codes (retrieval 58970, culture 89250/89272, ICSI 89280/89281, transfer 58974/58976, cryo 89258/89337) rather than a single global S-code; a service performed in the cycle that was not on the authorization letter (most often ICSI added on retrieval day, assisted hatching, or extended blastocyst culture 89272) denies as 'no authorization' even when the cycle itself was approved. Confidence medium — this reflects widely reported provider experience, not text in CP 0089.
- Cigna's national Master Precertification List (July 2026) lists the PGT lab codes 0552U–0555U as requiring precertification (effective 2025-07-01) but has no dedicated infertility section; infertility precertification is driven by the plan-specific infertility rider, so coverage/precert status must be checked per group.
- Many Cigna groups delegate fertility management to Cigna LifeSource or an outside vendor (Carrot, Progyny, WIN); an authorization submitted to standard Cigna when the vendor manages the benefit is denied or delayed (third-party source).
- Fertility drugs run through Express Scripts / Accredo specialty pharmacy under the pharmacy benefit (Cigna drug policies IP0333 GnRH agents, CNF 277 follitropins/clomiphene) with separate PA; a medical-benefit IVF authorization does not authorize the medications.
- Cycle-count and dollar-cap accounting varies by plan document (fresh cycles only vs. fresh+frozen; some count a cycle at retrieval, others at transfer); lifetime dollar maximums commonly include medications. 'In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.'
- Cryopreservation of embryos is covered 'only while the individual is currently under covered active infertility treatment' — storage fees after treatment ends (or after the benefit maximum is exhausted) shift entirely to the patient.
Appeal tips
- Denials for 'no infertility diagnosis': CP 0089 defines infertility by 'medical, sexual, and reproductive history; age, physical findings, diagnostic testing, or any combination of those factors' and explicitly includes people who need donor gametes 'regardless of relationship status or sexual orientation' — quote that language when a single or same-sex patient is denied for lacking 12 months of intercourse-based infertility, and attach the REI consult note with the diagnostic findings.
- ICSI or assisted-hatching denied as 'not authorized' on an approved cycle: this is usually a code-level authorization gap, not a medical-necessity finding. Have the clinic submit a retrospective authorization request with the retrieval-day semen analysis (for ICSI) or the specific CP 0089 hatching criterion met (age ≥38, elevated day-3 FSH, increased zona thickness, or ≥3 failed implantations) and ask that the existing cycle authorization be amended rather than filing a formal appeal.
- PGT-A: EviCore's guideline labels PGT-A 'not medically necessary' for maternal age, IVF success or recurrent loss, so internal appeal is unlikely to succeed. Pursue external review (state DOI for fully insured; independent review under ERISA for self-funded) with recent RCT/ASRM evidence, or, where a known monogenic/structural-rearrangement risk exists, re-request as PGT-M/PGT-SR with genetic counseling documentation, which meets the covered criteria.
- Request the specific policy version relied upon: CP 0089 was revised effective 2026-10-15 (ICSI criteria changed; sperm DNA integrity testing became covered; several 'unproven' items were removed). A denial issued after that date that cites 2025 language, or one issued before it for a service the new version covers, is grounds to demand re-review under the correct policy version.