Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility. 
Treatment: In-vitro fertilization (IVF) cycle. 

The insurer denied coverage for in-vitro fertilization (IVF) cycle. 

The denial is upheld. 

According to the documentation submitted, this patient had a history of infertility. She presented to the Reproductive Endocrinologist's office for a follow up visit. She had 9 oocytes cryopreserved. The patient would like to undergo a fresh in vitro fertilization cycle.  The 9 oocytes cryopreserved will be thawed and fertilized as well as the newly recovered eggs.  The embryos resulting from these eggs will undergo PGT-A (preimplantation genetic testing for aneuploidies) prior to transfer into the uterus. 

This patient has 9 oocytes that were cryopreserved years ago at an earlier age and are therefore considered much better quality than any recovered oocyte at her current age. Ideally, this patient will undergo fertilization of these oocytes (with PGT-A at her own expense if she so desires). At this time, there is no need for a fresh in vitro fertilization cycle. 

The aim of fertility treatment is to get pregnant and not to collect eggs or embryos. 
The patient might be able to complete her family with the 9 oocytes already preserved and therefore additional in vitro fertilization cycles are not medically necessary at this time. However, if thawing and fertilization of those frozen eggs does not result in a live birth, then the patient would be eligible for additional IVF cycles. Note that since those are younger eggs, the incidence of chromosomal anomaly should be less. 

Embryo aneuploidies may be responsible for implantation failures, miscarriages and affects IVF outcomes. A variety of technologies have been implemented to evaluate euploid embryos in IVF treatments (PGT-A). 

According to this strategy, a better embryo selection should increase IVF results. In reality, several issues remain unaddressed including the sampling strategy, involving the test outcomes, and the frequent occurrence of embryo mosaicism, affecting the criteria for selection of supposed viable embryos. Safety issues are in place, including peri-and post-natal consequences of embryo sampling and the epigenetic weaknesses from a prolonged in vitro culture. On the other side, chromosome number mistakes are progressively recognized as physiologic events in the early pre-implantation embryo with many corrective mechanisms in place and their destiny in the post-implantation development is unclear. Accordingly, the increasing precision of the diagnostic tools should be used to investigate the effect of such interventions within rigorous research programs in the sake of improved clinical outcomes. The diagnosis of embryo aneuploidies in IVF cycles should be considered as a research tool and systematic implementation in clinical practice may appear unjustified. 

This patient does not have any genetic anomaly and is not a carrier of a genetic condition or chromosomal anomaly known to cause the birth of a child with a genetic condition. In summary, there is no medical indication for PGT-A at this time. 

In vitro fertilization (IVF) cycle is not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for an in vitro fertilization (IVF) cycle is upheld. Medical Necessity is not substantiated.