Reply to IVF authorization denied - doesn't meet "medical necessity"

Forum Index » Infertility Support and Discussion

Reply to "IVF authorization denied - doesn't meet "medical necessity""

Subject:

Emoticons





More smilies

Text Color: Font: Close Marks

[quote=Anonymous]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![/quote]

Options

	Disable HTML in this message
	Disable BB Code in this message
	Disable smilies in this message

Review message

Search Recent Topics Hottest Topics