Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Female infertility
Treatment: 89290 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); less than or equal to five embryos
89291 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); greater than five embryos

The insurer denied the 89290 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); less than or equal to five embryos and 
89291 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); greater than five embryos.
The denial us upheld.



The health plan should not cover the proposed treatment.

The requested health service or procedure is unlikely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

The patient is a female with a diagnosis of infertility. She underwent two prior IVF (in vitro fertilization) cycles:

Cycle#1: No blastocyst development

Cycle#2: Three blastocysts, two abnormal. 

Neither the patient nor her partner are carriers of any chromosomal anomaly. 

Embryo aneuploidies may be responsible for implantation failures, miscarriages and affects 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. 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 be unjustified. 

Note that PGTA is not indicated for advanced maternal age or recurrent pregnancy loss or for recurrent implantation failures. ACOG stated the following:

"At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent."

ASRM also stated the following: "A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age."

It is important to note that PGS/PGT may lead to damage to the embryo and may have long-lasting health issues for the newborn. 

Note that neither the sensitivity nor the specificity of the test is 100%. 

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, this patient does not have any indication for:
89290 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); less than or equal to five embryos
89291 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); greater than five embryos.