HMSA has contracted with in vitro fertilization specialists in Hawaii to provide all services associated with the procedure based on negotiated rates. In vitro fertilization must be precertified.
However, should a member receive services outside the state of Hawaii and if the services were not precertified, the provider of the services must submit a copy of the patient's history and physical explaining how the patient meets the criteria stated in In Vitro Fertilization.
| CPT Code | Description |
|---|---|
| 58970 | Follicle puncture for oocyte retrieval, any method |
| 58974 | Embryo transfer, intrauterine |
| 76948 | Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation |
| 89250 | Culture of oocyte(s)/embryo(s), less than 4 days |
| 89251 | with co-culture of oocyte(s)/embryos |
| 89253 | Assisted embryo hatching, microtechniques (any method) |
| 89254 | Oocyte identification from follicular fluid |
| 89255 | Preparation of embryo for transfer (any method) |
| 89257 | Sperm identification from aspiration (other than seminal fluid) |
| 89260 | Sperm isolation; simple prep (e.g., sperm wash and swim-up) for insemination or diagnosis with semen analysis |
| 89261 | complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis |
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved |
| 89268 | Insemination of oocytes |
| 89272 | Extended culture of oocyte(s)/embryo(s), 4-7 days |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes |
| 89281 | greater than 10 oocytes |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos |
| 89291 | greater than 5 embryos |
| J0725 | Injection, chorionic gonadotropin per 1,000 USP units (Use this code for Corgonject-5, Novarel, Pregnyl) |
| J2675 | Injection, progesterone, per 50 mg. (Use this code for Gesterone, Gestrin) |
| J3355 | Injection, urufollitropin, 75 IU |
| S4011 | In vitro fertilization: including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of emtryos, and subsequent visualization for determination of development |
| S4015 | Complete in vitro fertilization cycle, not otherwise specified, case rate |
| S4017 | In complete cycle, treatment procedure cancelled before stimulation, case rate |
| S4020 | In vitro fertilization procedure, cancelled before aspiration, case rate |
| S4021 | In vitro fertilization procedure, cancelled after aspiration, case rate |
| S4022 | Assisted oocyte fertilization, case rate |
| S4028 | Microsurgical epididymal sperm aspiration (MESA) |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |