Neighborhood Health Plan

Policy Number
024
Policy Issued In
Massachusetts
Last Update
Next Update
Breast Reconstruction

NHP covers the following procedures for Male to Female: ... 6. Augmentation Mammoplasty

Related Policies
Breast Surgeries Medical Policy

Fertility Preservation

Related Policy: Infertility Services Medical Policy

Cryopreservation of Eggs/Embryos
NHP covers cryopreservation and storage for up to one year’s storage when authorized in accordance with this policy
and when one of the following criteria is met: ...
3. Female member will be undergoing medical treatment (e.g. chemotherapy, radiation, and gender reassignment)
excluding voluntary sterilization that is likely to result in permanent infertility, and NHP has authorized an IVF
cycle for stimulation and retrieval. Cryopreservation of eggs/embryos will be covered for up to one year from
the time of the egg retrieval.

Cryopreservation of Sperm
NHP covers cryopreservation and storage for up to one year’s storage for a male member who meets one of the
following criteria: ...
3. Male member will be undergoing medical or surgical treatment (e.g. chemotherapy, radiation, gender
reassignment surgery) excluding voluntary sterilization that is likely to result in permanent infertility. In this case
the male member and/or couple do not need to be already receiving NHP‐authorized in infertility services. There
must be a >5% probability of a future live birth using the member’s cryopreserved sperm.

In Vitro Fertilization (IVF) for Member not in Active Infertility Treatment
NHP covers one cycle of IVF for the purpose of egg retrieval, processing and fertilization and a single cryopreservation of eggs/embryos for up to one year, when there is documentation that a member will be undergoing medical or surgical
treatment (e.g. chemotherapy, radiation, gender reassignment), that is likely to result in permanent infertility.