Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Breast cancer
Treatment:  Retrieving and freezing eggs
The insurer denied Retrieving and freezing eggs.  The denial is overturned.

The retrieving and freezing of the eggs are medically necessary.

The patient is a G3 P2 Ab1 woman with a diagnosis of breast cancer.  Chemotherapy treatment has been planned.  The patient consulted a reproductive endocrinologist for the purpose of fertility preservation.  Embryo cryopreservation was recommended.

Prepubertal and adult female patients undergoing chemotherapy, surgery and/or radiation treatment for cancer may undergo serious ovarian damage.  The extent of ovarian damage is dependent on the type of treatment, as well as the age at the time of treatment.  Advancements in cancer therapies, particularly chemotherapeutics, have led to dramatic improvements in survival.  Cancer patients are surviving at increasing rates, but successful treatment in younger patients often leads to reduced fertility.  Given the reproductive risks of cancer therapies and improved long-term survival, there has been growing interest in expanding the reproductive options for cancer patients.  As the treatments for malignancies in females continue to improve their survival rates, increasing numbers of patients may seek preservation of their fertility. 

Fertility preservation treatments may include radical trachelectomy in cervical cancer, hormonal treatment of early endometrial cancer, and conservative surgical management of early-stage epithelial ovarian cancer for certain women with early invasive disease. Reducing the radiation dose to the ovary by shielding or surgically removing the ovaries from the field of radiation (i.e., oophoropexy) may preserve ovarian function. Suppression of folliculogenesis with GnRH (gonadotropin-releasing hormone) for fertility preservation has long been controversial. 

When patients can delay treatment, embryo and oocyte cryopreservation utilizing in vitro fertilization techniques can be offered and are now a standard of care.  Ovarian stimulation with retrieval and cryopreservation of oocytes and embryos can be performed, with later transfer of embryos to the patient or a gestational carrier. 

When facing gonadotoxic chemotherapy, the option(s) of freezing of embryos for females have been established method(s) for many years.  The medical community has acknowledged the importance of patient counseling and pursuit of options for fertility preservation.  With regard to adult females, the American Society of Clinical Oncology recommendations include presenting both embryo and oocyte cryopreservation as established fertility preservation methods.  Ovarian stimulation for embryo or mature oocyte cryopreservation remains the most likely strategy to result in subsequent pregnancy.  This procedure should be recommended as long as the patient's medical condition does not preclude safely carrying out controlled ovarian stimulation (COS) or oocyte retrieval, the patient has a reasonable chance of responding to COS, and adequate time is available to undergo COS and carry out oocyte retrieval.

The American Society for Reproductive Medicine, in its Practice Committee Opinion, recommends that the most established strategy for preservation of female fertility is for a woman to undergo a cycle of IVF (in vitro fertilization) and create embryos for later use.  Established methods of fertility preservation include sperm cryopreservation in men and embryo and oocyte cryopreservation in women. 

The Optum Health Plan guidelines state: "The following procedures are proven and medically necessary for diagnosing or treating infertility:...Cryopreservation of...embryos for individuals who are...planning to undergo therapies that threaten their reproductive health, such as cancer chemotherapy."  The medical records indicate that embryo cryopreservation was planned.  Therefore, the patient meets the standard of care and the Health Plan definition for medical necessity.