S4030 Sperm procure init visitSperm procurement and cryopreservation services; initial visit
Status I: not valid for Medicare (Medicare uses another code).
12 of 12 payer prior-auth lists that name S4030 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Humana, Molina Healthcare of California, Neighborhood Health Partnership, Oxford Health Plans, Surest, UnitedHealthcare.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth required | 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 | ||
| Molina Healthcare of California | California state exceptions (exceptions only) | CA | prior auth required | State exception; These services are covered with Prior Authorization in accordance with Senate Bill 600 | Jul 1, 2021 | California PA code exceptions (Marketplace), Q3 2021 |
| 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 |
S4030 appears in 10 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross.
| 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 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 | |
| Blue Shield of California | | Reproductive Techniques (4.02.04) | listed, no stance | payer document | |
| Cigna | Infertility Services (0089) | covered if criteria are met | Jun 15, 2025 | payer document |
| Cigna | Infertility Services (0089) | not covered | Jun 15, 2025 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Reproductive Techniques and Immunotherapy for Recurrent Fetal Loss (OB402.023) CPT Codes 55899, 58322, 58340, 58999, 76831, 82397, 83519, 83520, 86148, 86357, | listed, no stance | Jan 1, 2026 | payer document |
| Premera Blue Cross | Infertility and Assisted Reproduction Services | listed, no stance | May 11, 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.