Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility

Treatment: 89253, intracytoplasmic sperm injection (ICSI) and code 89290, preimplantation genetic testing (PGT)

The insurer denied coverage for 89253, intracytoplasmic sperm injection (ICSI) and code 89290, preimplantation genetic testing (PGT)

The denial is upheld

 
The patient has a diagnosis of infertility. She underwent the following services: code 89253, intracytoplasmic sperm injection (ICSI) and code 89290, preimplantation genetic testing (PGT). 

The insurer has denied coverage for code 89253, intracytoplasmic sperm injection (ICSI) and code 89290, preimplantation genetic testing (PGT) as not medically necessary. In a Final Adverse Determination letter they stated that PGT-A has not been shown to improve clinical outcomes for women of advanced maternal age. 

Note that neither the sensitivity nor the specificity of the test is 100%.  Note that many embryos considered abnormal were transferred resulting in healthy live births.

The American Society for Reproductive Medicine (ASRM) is in an opinion on the use of preimplantation genetic testing (PGT) for aneuploidy in 2018 which was informed by literature search or relevant trials. The committee concluded that "the value of preimplantation genetic testing for aneuploidy as a universal screening test for all IVF patients has yet to be determined."

 As per the American College of Obstetrics and Gynecology (ACOG) Committee Opinion #799, "The clinical utility of preimplantation genetic testing-monogenic and preimplantation genetic testing-structural rearrangements is firmly established; however, the best use of preimplantation genetic testing-aneuploidy remains to be determined. Future research is necessary to establish the overall clinical utility for preimplantation genetic testing-aneuploidy, the subset of patients that may benefit from preimplantation genetic testing-aneuploidy, the clinical significance of mosaicism, and residual risk for aneuploidy in preimplantation genetic testing-aneuploidy screened embryos." 

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 addition, ICSI for non-male factor infertility has not been shown to improve live birth rates, on the contrary.

With regard to this patient, the diagnosis of polycystic ovary syndrome (PCOS) is felt to be supportive for the requested procedures. However, there is no scientific evidence that patients with PCOS have evidence of more aneuploid embryos. In patients with PCOS, the decreased fertility is usually attributed to higher Body Mass Index (BMIs), inflammation, and higher glucose levels in patients with PCOS.

Neither ACOG nor ASRM suggest or recommend PGT-A in patients with PCOS.

In summary, this patient does not have any indication for: code 89253, intracytoplasmic sperm injection (ICSI) and code 89290, preimplantation genetic testing (PGT).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for code 89253, intracytoplasmic sperm injection (ICSI) and code 89290, preimplantation genetic testing (PGT) is not substantiated.