Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility. 
Treatment: 89290 - Assisted oocyte fertilization, microtechnique; le than or equal to 10 oocytes; 89281 - Assisted oocyte fertilization, microtechnique; greater than 10 oocytes; 89290 - Biopsy, oocyte polar body or embryo blatomere, microtechnique (for pre-implantation genetic diagnosis), less than or equal to 5 embryos; and 89291 - Biopsy, oocyte polar body or embryo blatomere, microtechnique (for pre-implantation genetic diagnosis), greater than 5 embryos. 

The insurer denied coverage for 89290 - Assisted oocyte fertilization, microtechnique; le than or equal to 10 oocytes; 89281 - Assisted oocyte fertilization, microtechnique; greater than 10 oocytes; 89290 - Biopsy, oocyte polar body or embryo blatomere, microtechnique (for pre-implantation genetic diagnosis), less than or equal to 5 embryos; and 89291 - Biopsy, oocyte polar body or embryo blatomere, microtechnique (for pre-implantation genetic diagnosis), greater than 5 embryos. 

The denial is upheld. 

According to the documentation submitted, this is a female with 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. 

According to ASRM (American Society for Reproductive Medicine), ICSI (intracytoplasmic sperm injection) for unexplained infertility has been associated with increased fertilization rates and decreased risk of failed fertilization in some studies but has not been shown to improve live-birth outcomes.  In addition, there are no studies addressing whether ICSI of poor-quality oocytes improves live-birth rates.  ICSI for low oocyte yield and advanced maternal age does not improve live-birth outcomes. 
In summary, ICSI for this patient is not indicated or medically necessary since the sperm is reported to be normal. Actually, the scientific literature documents a decrease in live birth in patients undergoing ICSI in non-male infertility patients. 

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 or ICSI at this time. 

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

The insurer's denial of coverage for 89290 - Assisted oocyte fertilization, microtechnique; le than or equal to 10 oocytes; 89281 - Assisted oocyte fertilization, microtechnique; greater than 10 oocytes; 89290 - Biopsy, oocyte polar body or embryo blatomere, microtechnique (for pre-implantation genetic diagnois), less than or equal to 5 embryos; and 89291 - Biopsy, oocyte polar body or embryo blatomere, microtechnique (for pre-implantation genetic diagnosis), greater than 5 embryos is upheld. Medical Necessity is not substantiated.