Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diminished ovarian reserve

Treatment: in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI), and pre-implantation genetic testing (PGT) and gonadotropins, codes 58970, 76948, 89250, 89253, 89254, 89255, 89260, 89261, 89268, 89272, 89280, 89281, 89258, 89342

The insurer denied coverage for in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI), and pre-implantation genetic testing (PGT) and gonadotropins, codes 58970, 76948, 89250, 89253, 89254, 89255, 89260, 89261, 89268, 89272, 89280, 89281, 89258, 89342 

The denial is upheld

This patient is an adult female interested in conceiving with donor sperm. According to the provider's note, the patient has failed 5 inseminations. The provider is requesting coverage for in vitro fertilization, intracytoplasmic sperm injection, embryo freezing and storage and pre-implantation genetic testing (PGT).

The patient is not known to be the carrier of any chromosomal anomaly or genetic disease.

The patient is reported to be unable to tolerate ovulation and has been hospitalized twice with severe nausea and gastric discomfort.

According to the American Society for Reproductive Medicine (ASRM) definition of infertility: In the absence of exigent history or physical findings, evaluation should, and treatment may be, initiated at 6 months in women aged 35 or older.

This patient has undergone 5 inseminations with donor sperm. According to the standard of care, she does not have a diagnosis of infertility and is therefore not eligible for infertility treatment including, in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) and pre-implantation genetic testing (PGT-A).

According to the American Society for Reproductive Medicine (ASRM), intracytoplasmic sperm injection (ICSI) 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.

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.
ICSI for this patient is not medically necessary.

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

According to this strategy, a better embryo selection should increase IVF results. 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. The diagnosis of embryo aneuploidies in IVF cycles should be considered as a research tool and systematic implementation in clinical practice may appear unjustified. 

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.

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 the following services are not medically necessary: 58970, 76948, 89250, 89253, 89254, 89255, 89260, 89261, 89268, 89272, 89280, 89281, 89258, 89342.

While the patient is unable to tolerate ovulation, she could undergo a natural cycle donor insemination.

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 in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI), and pre-implantation genetic testing (PGT) and gonadotropins, codes 58970, 76948, 89250, 89253, 89254, 89255, 89260, 89261, 89268, 89272, 89280, 89281, 89258, 89342 is not substantiated.