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It specifies eligibility criteria, including risks from surgery, radiation, chemotherapy, gonadotoxic medications, and other reproductive impacts. The guideline outlines covered services such as cryopreservation, oocyte retrieval and culture, embryo hatching, insemination, medications, and related laboratory testing. It also details required documentation for authorization, plus stated limitations and exclusions, coding and standards, legal and compliance approvals, and reference materials, including dates and effective implementation.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/evh-clinical-guideline-2737cc-for-fertility-preservation-for-iatrogenic-infertility-policy-overview/403420/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/evh-clinical-guideline-2737cc-for-fertility-preservation-for-iatrogenic-infertility-policy-overview/403420.png","ImageObject",300,407,{"name":92,"@type":93},"adawds","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-27",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What makes fertility preservation medically necessary under this guideline?","Question",{"text":112,"@type":113},"Fertility preservation services are medically necessary for members at risk of iatrogenic infertility due to treatments such as surgery, radiation, chemotherapy, gonadotoxic medications, or other therapies affecting reproductive processes.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"Which services are included for fertility preservation?",{"text":117,"@type":113},"Services include office visits, pelvic ultrasounds, sperm and oocyte cryopreservation and storage, oocyte retrieval and culture, assisted embryo hatching, insemination of oocytes, medications/injectables, and laboratory testing and analyses.",{"name":119,"@type":110,"acceptedAnswer":120},"What documentation may be required to authorize the services?",{"text":121,"@type":113},"Authorization may require clinical documentation such as initial history and physical, rationale for the treatment plan, ovarian stimulation sheets, operative reports, relevant lab results (FSH, AMH, estradiol, etc.), ultrasound findings, HSG report, semen analysis, genetic testing, and testicular biopsy reports.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},403420,1790808657,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":39,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":46,"preview_page_count":4},3985747872983,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","EVH Clinical Guideline 2737.CC for Fertility Preservation for Iatrogenic Infertility  \n\n| Guideline Number:\u003Cbr>EVH_CG_2737.CC | Applicable Codes |  |\n| --- | --- | --- |\n| \"Evolent\" refers to Evolent Health LLC and Evolent Specialty Services, Inc.© 2023-2026 Evolent. All rights Reserved. |  |  |\n| Original Date:\u003Cbr>July 15, 2023 | Last Revised Date:\u003Cbr>December 9 , 2025 | Implementation Date:\u003Cbr>January 1, 2026 |\n\nTABLE OF CONTENTS  \nSTATEMENT ................................................................................................................................................ 2  \nGENERAL INFORMATION ............................................................................................................................... 2  \nSPECIAL NOTE ............................................................................................................................................ 2  \nINDICATIONS ............................................................................................................................................... 2  \nSERVICES ................................................................................................................................................... 3  \nDOCUMENTATION ........................................................................................................................................ 3  \nLIMITATIONS AND EXCLUSIONS .............................................................................................................. 3  \nCODING AND STANDARDS ....................................................................................................................... 4  \nCODES ........................................................................................................................................................ 4  \nAPPLICABLE LINES OF BUSINESS .................................................................................................................. 6  \nPOLICY HISTORY ........................................................................................................................................ 6  \nLEGAL AND COMPLIANCE ........................................................................................................................ 6  \nGUIDELINE APPROVAL ................................................................................................................................. 6  \nCommittee ............................................................................................................................................. 6  \nDISCLAIMER ................................................................................................................................................ 7  \nREFERENCES.............................................................................................................................................. 8  \nSTATEMENT  \nGeneral Information  \n● It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.  \n● Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines, and state/national recommendations.  \n● The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.  \nSpecial Note  \nPublic Act 100-1102 require","cbCaie28UG0I6Zzq","https://ap.wps.com/l/cbCaie28UG0I6Zzq","pdf",270387,"English","# STATEMENT\n## General Information\n## Special Note\n# INDICATIONS\n# SERVICES\n# DOCUMENTATION\n# LIMITATIONS AND EXCLUSIONS\n# CODING AND STANDARDS\n## CODES\n## Applicable Lines of Business\n# POLICY HISTORY\n# LEGAL AND COMPLIANCE\n# GUIDELINE APPROVAL\n## Committee\n# DISCLAIMER\n# REFERENCES","[{\"question\":\"What makes fertility preservation medically necessary under this guideline?\",\"answer\":\"Fertility preservation services are medically necessary for members at risk of iatrogenic infertility due to treatments such as surgery, radiation, chemotherapy, gonadotoxic medications, or other therapies affecting reproductive processes.\"},{\"question\":\"Which services are included for fertility preservation?\",\"answer\":\"Services include office visits, pelvic ultrasounds, sperm and oocyte cryopreservation and storage, oocyte retrieval and culture, assisted embryo hatching, insemination of oocytes, medications/injectables, and laboratory testing and analyses.\"},{\"question\":\"What documentation may be required to authorize the services?\",\"answer\":\"Authorization may require clinical documentation such as initial history and physical, rationale for the treatment plan, ovarian stimulation sheets, operative reports, relevant lab results (FSH, AMH, estradiol, etc.), ultrasound findings, HSG report, semen analysis, genetic testing, and testicular biopsy reports.\"}]","EVH Clinical Guideline 2737.CC for Fertility Preservation for Iatrogenic Infertility - Policy Overview | PDF",1790540330]