S4011 Ivf packageIn vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
Status I: not valid for Medicare (Medicare uses another code).
13 of 13 payer prior-auth lists that name S4011 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Humana, Neighborhood Health Partnership, Oxford Health Plans, Surest, UnitedHealthcare.
S4011 appears in 18 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, BlueCross BlueShield of South Carolina, Centene, Cigna, Premera Blue Cross, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Infertility (0327) | covered if criteria are met | Jul 16, 2026 | payer document |
| Aetna | Invasive Prenatal Diagnosis of Genetic Diseases (0358) | listed, no stance (range S4011-S4022) | May 22, 2026 | payer document |
| Aetna | Preconceptional Sex Selection Techniques (0323) | listed, no stance (range S4011-S4042) | May 20, 2026 | payer document |
| Anthem | Assisted Reproductive Technology (CG-MED-103) | covered if criteria are met | Nov 6, 2025 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Expanded Fertility Services | covered if criteria are met | Dec 3, 2025 | payer document |
| Blue Cross & Blue Shield of Rhode Island | Infertility Services | covered if criteria are met | Dec 3, 2025 | payer document |
| Blue Cross Blue Shield of Massachusetts | Assisted Reproductive Servies Infertility Services (086) | listed, no stance | payer document | |
| BlueCross BlueShield of South Carolina | Reproductive Techniques (CAM 40204) 0357T | Cryopreservation; immature oocyte(s) | listed, no stance | Apr 1, 2026 | payer document |
| Centene | Assisted Reproductive Technology (CP.MP.55) | covered if criteria are met | Feb 1, 2025 | payer document |
| Cigna | Infertility Services (0089) | not covered | Jun 15, 2025 | payer document |
| Premera Blue Cross | Infertility and Assisted Reproduction Services | listed, no stance | May 11, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (CS160.N) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (for Kansas Only) (CS160KS.03) | listed, no stance | Jun 1, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (for Kentucky Only) (CS161KY.09) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (for Nebraska Only) (CS160NE.F) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (for New Mexico Only) (CS160NM.E) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (for Pennsylvania Only) (CS160PA.L) | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | Preimplantation Genetic Testing and Related Services (for Tennessee Only) (CS160TN.M) | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in IN.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.