IVF authorization denied - doesn't meet "medical necessity"
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Anonymous
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I'm not in DC (in CT), but I read these forums all the time. I figured the wise people here could lend some perspective!
After 3 miscarriages (most likely chromosomal abnormalities), tests turning up normal, etc., we've decided to go the IVF route. Our RE recommended this with PGS testing. We were on my insurance but it didn't cover IVF, so we switched to Husband's. It took effect July 1 and we were ready to roll. Clinic submitted the authorization July 2 and we just heard last week it was denied: insurance says there's no documentation that I've been unable to conceive or sustain after 3 trials of IUI in one year; I don't meet the "medical necessity criteria." Obviously, IUI isn't going to address the most likely cause of my miscarriages, which is why the Dr. recommended IVF with testing. Well, testing isn't covered (nor is freezing/banking), so we've already paid that portion out-of-pocket. We are angry and feel as though out Dr/clinic dropped the ball: the documentation explaining why we need to go straight to IVF should have been submitted initially (because the plan does allow lesser treatments to be skipped of the Dr. explains why they are unlikely to be effective). Here we are, starting an appeal. I'm nervous it will take forever and could weaken the legitimacy of the claim (if that makes sense...). Also, as I mentioned, freezing/banking is not covered: the whole point of this is the PGS, and even though we are paying that portion ourselves, I'm worried that will also impact the decision because it is submitted as a "IVF/Freeze all cycle" Anyone been through a similar rollercoaster with insurance? Is there hope or are we going to have to find a way to pay? Thank you all! |
Anonymous
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I really sympathize with your situation. Here is what I know from 4+years of IF and dealing with insurances:
0) read your insurance "statement of medical policy" relating to infertility, miscarriages and PGS. Know it by heart, like "Hail Mary". For an appeal you have to prove that your denial was against this policy. I.e. you need to find the place in the book that says you're covered for PGS for the reasons of RPL (repetitive pregnancy loss). 1) PGS is usually covered only for specific genetic disorders, for which you need to do Counsil test (both you and spouse). Eg. Tay-Sachs, fragile X, etc. Meaning: you need a diagnosis of genetic disorder. For everything else, freezing, biopsy and testing is considered "experimental". At least from what I've seen. 2) In cases of repeated miscarriage, you need a diagnosis. "likely" doesn't work for insurance folks. There is a way to have tissues tested genetically after a miscarriage to establish the reason. Have you done D&C after any of the miscarriages? Sometimes they keep sample of tissue, which can be sent to testing post-factum. 3) IUIs are easy and don't take much time for prep - you could be done in 3 months with the insurance requirement. Ask your doctor if you can defer your payment out of pocket until insurance kicks in. Take a long hard look at your clinic: they are the ones who should already know all this and explain it to you. They may be after your money... Any IF clinic worth its salt knows how to submit these claims. |
Anonymous
| Can you just do the IUIs? Might be faster |
Anonymous
| Op here. Coverage is for under 40 and I am 39, hence the urgency. If we started before 40, perhaps it’s viewed/weighed collectively? |
Anonymous
18:56 PP here. No, multiple IVF rounds are not viewed "collectively". Each requires a separate authorization, but for now your problem is that you don't seem to fall under the criteria for authorization. Until a doctor can give you a diagnosis that qualifies you for IVF - you're stuck. Have you had any testing done after 3rd miscarriage? Have you done a genetic test (and your spouse as well)? These would normally be covered by insurance and would be the first steps to document why you may need PGD and only PGD to proceed. Call your insurance, there should be a separate team dealing with fertility-related claims. Write down your questions, have a detailed talk with them. They will not be able to reverse the previous decision on the spot, but they will give you the info that you're missing right now: what you need from your dr. in order for the claim to be reviewed and possibly approved. I can't speak for all insurance ppl, but the team who I talked to at Aetna were invariably very compassionate, friendly and patient, I never walked away from the call without the info I needed broken down to my level of non-medical understanding. Knowledge is power, go for it. |
Anonymous
| I have a good friend who worked for a law firm in CT whose clients were insurance companies (so he was familiar with their internal policies). He said several companies had a blanket policy of denying all claims on the first round regardless of merit because a certain portion of people won’t appeal and it saves them money. I would talk to your dr about giving you a diagnosis that will work (often this is as easy as coding the paperwork differently) and appeal right away. |
Anonymous
| Hi OP, I had miscarriages in my 30s too and all the tests were normal as well. I changed my diet and ended up having 2 kids (naturally) and currently halfway through #3. So if you haven't tried dietary changes, it might be worth considering, in addition to your other approaches. In my case I didn't have digestion issues and I honestly wasn't expecting much, but so glad I tried it. Good luck! |
Anonymous
Can you describe in a nutshell what you changed or give a link to your diet? |
Anonymous
Pretty please??? 
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Anonymous
Sure. In a nutshell, my diet became only good quality meat, variety of seafood, lots of the best quality produce I could find (I’m on the west coast where that isn’t as difficult as I think probably is on the east coast), good quality pastured eggs, raw milk and cream from a farm I trust, a variety of nuts and sprouted seeds. No gluten or soy, and hardly anything from a packet. Our food bill went WAY up (DH was doing it with me) and making food took way longer. I waited several months to try to get my body healthier and then tried again, and it worked. To this day, I'm not sure what exactly it was - maybe it was the fact that I couldn't handle gluten or soy or something and it was setting off some sort of reaction in my body and I just didn’t have any signs and never knew it, or maybe it was just that the new diet with such a lot of good food filled in some deficiency that I had and didn't know about, or maybe a combination of lots of things. Maybe it was all in my imagination somehow (unlikely, but I’m sure some people believe that, and hey, I can’t prove it isn’t true). I know some people think I'm crazy but I couldn’t care less. I have kids now that I didn't have before. I strongly feel I wouldn’t have been able to have healthy pregnancies if I’d continued on the path I was on, and so it has been more than worth it to me. I don’t think that everyone needs to eat this way, and even the people who need to eat differently might not need to go to such extremes, but for me I was desperate and I wanted to cover all the bases and give myself the best shot I could. Maybe it was just one small change that was necessary, but only my body knew what it was and unfortunately it wasn't talking
Hope that helps! |
Anonymous
| I hate when people say diet will allow you to get pregnant on your own. It’s just not true. But eating healthy is always a great thing! |
Anonymous
The causes of infertility are different for each woman. I would've had the same problems regardless of my age or diet. But diet and lifestyle (physical fitness, weight, etc) can certainly be the culprits for other women. |
Anonymous
| If your DH employer has a broker for the insurance, sometimes they can get results that the employee or even HR cannot. |
Anonymous
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I also believe that diet, weight and activity play a huge role....I go as far as also saying that sunshine matters too. I have been pregnant 4 times in my life all when I was at a perfect weight, eating healthy and in the summer time. The first ended in miscarriage at 7.5 weeks, the second ended at 7 weeks (low progesterone) and the third ended in an ectopic. The 4th ended in a healthy baby boy with only having one tube to get naturally pregnant with but only because I basically threatened the doctor to put me on progesterone even though my levels were in range. I weighed much less and was eating very healthy in all these cases and spending time in the sunshine-beach trips, lots of pool time. I have spent since this past winter trying to get pregnant. Only last month and this month are my AFCs and retrievals at an all time time..... "unexplained" jump.... started eating super healthy 2 months ago and lost 20 pounds.
For those us who are unexplained basically, it literally takes EVERYTHING to be perfect....including our weight, food intake, amount of Vitamin D from sunlight, etc. to get pregnant. I say appeal but start the IUIs asap. Make sure you are eating right, staring at the sun, and are at a healthy weight when you start IVF. Fingers crossed for you! |
Anonymous
. I lost 20lbs in the year I was trying to conceive and did IVF also during that time. Got to my ideal weight. . Ate healthy. Working out 6times per week!! Further made me depressed considering my labs and everything were perfect and no pregnancy.. Every woman is different. Fertility is a crap shoot to be honest!! |