Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility
Treatment: Infertility services - second in vitro fertilization (IVF), medication, freezing and storage of embryos medically necessary for this patient [Current procedural terminology (CPT) codes S4015 - Complete In Vitro Fertilization Cycle, Not Otherwise Specified; 89280 - Assisted Fertilization Microtech less than or equal to 10 Oocytes; 89281 - Assisted Fertilization Microtech greater than (>) 10 Oocytes; 89290 - Biopsy (Bx) Oocyte Microtech less than or equal to 5 Embry; 89291 - Biopsy (Bx) Oocyte Microtech > 5 Embry; 89258 - Cryopreservation Embryo; 89342 - Storage Embryo; 58970 - Retrieval of Oocytes; 58974 - Embryo Transfer Intrauterine; S0122 - Injection, Menotropins; 75 IU S0128 - Injection, Follitropin Beta, 75 international units (IU)]
The insurer denied infertility services - second in vitro fertilization (IVF), medication, freezing and storage of embryos medically necessary for this patient [Current procedural terminology (CPT) codes S4015 - Complete In Vitro Fertilization Cycle, Not Otherwise Specified; 89280 - Assisted Fertilization Microtech less than or equal to 10 Oocytes; 89281 - Assisted Fertilization Microtech greater than (>) 10 Oocytes; 89290 - Biopsy (Bx) Oocyte Microtech less than or equal to 5 Embry; 89291 - Biopsy (Bx) Oocyte Microtech > 5 Embry; 89258 - Cryopreservation Embryo; 89342 - Storage Embryo; 58970 - Retrieval of Oocytes; 58974 - Embryo Transfer Intrauterine; S0122 - Injection, Menotropins; 75 IU S0128 - Injection, Follitropin Beta, 75 international units (IU)].
The determination is upheld.

The patient has a diagnosis of infertility. She has previously undergone in vitro fertilization (IVF)) and has a euploid blastocyst remaining. At issue is the medical necessity of a second IVF cycle [Current procedural terminology (CPT) codes S4015 - Complete In Vitro Fertilization Cycle, Not Otherwise Specified; 89280 - Assisted Fertilization Microtech less than or equal to 10 Oocytes; 89281 - Assisted Fertilization Microtech greater than (>) 10 Oocytes; 89290 - Biopsy (Bx) Oocyte Microtech less than or equal to 5 Embry; 89291 - Biopsy (Bx) Oocyte Microtech > 5 Embry; 89258 - Cryopreservation Embryo; 89342 - Storage Embryo; 58970 - Retrieval of Oocytes; 58974 - Embryo Transfer Intrauterine; S0122 - Injection, Menotropins; 75 IU S0128 - Injection, Follitropin Beta, 75 international units (IU)].

The requested services are not necessary for medical treatment of infertility as this patient currently has a euploid blastocyst available for embryo transfer.

The patient has infertility and currently has a euploid blastocyst available. The next step, an embryo transfer, is the best option for immediate treatment of the medical problem, infertility, not the creation of additional embryos.

The embryo grade was noted to be 1BB. What this translates to be is an early blastocyst with an inner cell mass that is loosely grouped with several cells and trophectoderm with few cells. This is a poor quality embryo in these regards but it is chromosomally normal. As it is a viable embryo, though poor quality, this does not mean that it cannot result in a pregnancy though the chances of success are less than a higher graded embryo. The patient has a viable embryo that can result in pregnancy which would be a reasonable treatment for her infertility. Thus, it is medically reasonable and standard to transfer this embryo prior to creating additional embryos.

Therefore, the requested services are not medically necessary.