Permissible Exclusions

Section 2015.60  Permissible Exclusions a)         Reversal of voluntary sterilization; however, in the event a voluntary sterilization is successfully reversed, infertility benefits shall be available if the covered individual meets the definition of "infertility" as set forth in Section 2015.30 of this Part. b)         Payment for services rendered to a surrogate after the surrogate has been discharged to regular obstetrical care, non-medical expenses incurred by the covered individual to contract with the surrogate, and any other services rendered to a surrogate that are not directly related to treatment of the covered individual’s infertility. c)         Expenses for cryopreservation and storage of sperm, eggs, and embryos. The exclusion must not apply to costs for subsequent procedures of a medical nature necessary to make use of the cryopreserved and stored substance if the procedures are deemed non-experimental and non-investigational. The exclusion also must not apply to expenses for cryopreservation when a covered individual receives those services under the conditions provided in Section 356z.32 of the Code relating to iatrogenic infertility; d)         Non-medical costs of a donor or a surrogate; e)         Travel costs for travel within 100 miles of the insured's or member's home address as filed with the insurer or health maintenance organization, travel costs not medically necessary, not mandated or required by the insurer or health maintenance organization; f)         Infertility treatments deemed experimental in nature.  However, where infertility treatment includes elements which are not experimental in nature along with those which are, to the extent services may be delineated and separately charged, those services which are not experimental in nature shall be covered.  No insurer or HMO required to provide infertility coverage shall deny reimbursement for an infertility service or procedure on the basis that such service or procedure is deemed experimental or investigational unless supported by the written determination of the American Society for Reproductive Medicine (formerly known as the American Fertility Society or the American College of Obstetrics).  These entities will provide such determinations for specific procedures or treatments only and will not provide determinations on the appropriateness of a procedure or treatment for a specific individual.  Coverage is required for all procedures specifically listed in Section 356m of the Code, regardless of experimental status.