HCPCS Level II › S codes S4028 Microsurg epi sperm aspMicrosurgical epididymal sperm aspiration (mesa)
Medicare coverage: Not payable by Medicare Status: active (October 2026 file) Medicare pricing for S4028 Physician Fee Schedule (CY 2026, RVU26D) Status I: not valid for Medicare (Medicare uses another code).
Payer policies and prior authorization for S4028 12 of 12 payer prior-auth lists that name S4028 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Humana, Neighborhood Health Partnership, Oxford Health Plans, Surest, UnitedHealthcare, UnitedHealthcare Community Plan.
Payer Plan State Prior auth Conditions Since Source Blue Cross Blue Shield of Arizona (AZ Blue) Federal Employee Program (FEP) AZ prior auth under conditions FEP Standard Plan only Sep 1, 2026 Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) Blue Cross Blue Shield of Arizona (AZ Blue) Teamsters group (TYW) AZ prior auth required Sep 1, 2026 Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) Humana Oak Street Health All prior auth required Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management Neighborhood Health Partnership Neighborhood Health Partnership FL prior auth required Sep 1, 2026 Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 Oxford Health Plans Oxford Health Plans All prior auth required Oct 1, 2026 Prior Authorization Requirements for Oxford Effective October 1, 2026 Surest Surest health plans All prior auth required Oct 1, 2026 Prior Authorization Requirements for Surest Effective October 1, 2026 UnitedHealthcare UnitedHealthcare Commercial All prior auth required Oct 1, 2026 Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 UnitedHealthcare UnitedHealthcare Individual Exchange plans All prior auth under conditions not in NM, SC, WI Oct 1, 2026 Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 UnitedHealthcare UnitedHealthcare Mid-Atlantic Health Plans All prior auth required Oct 1, 2026 Prior authorization requirements for UnitedHealthcare Mid-Atlantic Health Plans Effective October 1, 2026 UnitedHealthcare UnitedHealthcare West commercial plans All prior auth required Oct 1, 2026 Prior authorization requirements for UnitedHealthcare West commercial plans Effective October 1, 2026 UnitedHealthcare UnitedHealthcare of the River Valley All prior auth required Oct 1, 2026 Prior authorization requirements for UnitedHealthcare of the River Valley Effective October 1, 2026 UnitedHealthcare Community Plan Maryland HealthChoice MD prior auth required Sep 1, 2026 Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026
Payer coverage policies that name S4028 S4028 appears in 12 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, 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 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 ServicesMEDICAL COVERAGE POLICY | 13 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 Blue Shield of California | Reproductive Techniques (4.02.04) listed, no stance payer document Centene Assisted Reproductive Technology (CP.MP.55) covered if criteria are met Feb 1, 2025 payer document Centene Fertility Preservation (CP.MP.130) covered if criteria are met Jan 1, 2026 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 Infertility Diagnosis, Treatment, and Fertility Preservation (2026T0270NN) listed, no stance Jun 1, 2026 payer document
Recent prior-auth changes Mar 1, 2026: PA removed, UnitedHealthcare Sep 1, 2025: conditions changed, UnitedHealthcare May 1, 2025: conditions changed, UnitedHealthcare Dec 1, 2024: conditions changed, UnitedHealthcare Medicaid fee-for-service Prior authorization required or conditional in IN.
ND: $0.00 (physician), effective Aug 1, 2026 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.