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 with a history of Hodgkin's lymphoma and Crohn's disease. She presented to the reproductive endocrinologist's (RE) office for a consultation regarding oncofertility. The physician recommended embryo cryopreservation to preserve the patient's fertility prior to oncology treatments. Ovarian reserve and preconception bloodwork would be obtained. In vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) and preimplantation genetic testing for aneuploidy (PGT-A) would be done. 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.

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

It is important to note that embryo biopsy 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 5 embryos or 89291 - Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic screening); greater than 5 embryos. Both 89290 and 89291 are not medically necessary.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. Procedure codes 89290 and 89291 do not need and do not have final approval from the appropriate regulatory bodies for this diagnosis. This patient is not a good candidate for procedure codes 89290 and 89291. Procedure codes 89290 and 89291 are not the best available treatment for this patient at this time. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. The adverse risks are increased over standard treatment/services.

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.