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

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[quote=Anonymous]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.[/quote]

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