Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hodgkin's lymphoma.
Treatment: Procedure code 89290 biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and procedure code 89291, biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.

The insurer denied coverage for procedure code 89290 biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and procedure code 89291, biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.  The denial is upheld.

The patient is a female gravida (G)2 pre-term delivers (P)2 with a history of Hodgkin's Lymphoma. She had previously undergone chemotherapy and immunotherapy in 2019. The patient was diagnosed with a recurrence. Immunotherapy with eventual stem cell or bone marrow transplantation was planned. Fertility preservation was sought. In vitro fertilization (IVF), preimplantation genetic testing or aneuploidy (PGT-A) and embryo cryopreservation was recommended by her reproductive endocrinologist.

The medical records and medical literature were thoroughly reviewed. 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 gonadotropin-releasing hormone (GnRH) as 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. 

The carrier's denial of procedure codes 89290 biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and procedure code 89291, biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be upheld.