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
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 patient is a female with history of five miscarriages.  She has been diagnosed with recurrent pregnancy loss (RPL). The plan is for IVF (in vitro fertilization) with PGT-A (Preimplantation Genetic Testing for Aneuploidy).

According to Schattman, the majority of conceptions that end in spontaneous miscarriage and are successfully karyotyped demonstrate a chromosomal abnormality, typically aneuploidy (loss or gain of an entire chromosome), but some are related to duplication or deletion of a portion of the chromosome (segmental aneuploidy) or to mosaicism. Recurrent aneuploidy may account for some cases of recurrent pregnancy loss (RPL), regardless of maternal age.
In couples who have experienced RPL and have a history of proven aneuploid abortuses, PGT-A has been proposed to select euploid embryos for transfer, which might increase the implantation rate, lower the spontaneous loss rate, and thus improve pregnancy outcome. For couples with RPL who have had proven euploid miscarriages, PGT-A is unlikely to be of benefit.
According to Masbou et al, "two of the many milestone developments in the field of assisted reproduction have been oocyte donation and preimplantation genetic testing for aneuploidy (PGT-A). Because it has been demonstrated that even young women produce a meaningful proportion of aneuploid embryos, screening out such abnormalities could potentially increase the efficacy of donor egg (DE) cycles. In this retrospective cohort study, we investigated the effect of PGT-A on DE cycle outcomes, including implantation rate (IR), spontaneous abortion rate (SABR), and ongoing pregnancy/live birth rate. We used fresh and frozen donor cycles not using PGT-A as comparison groups; all cases involved single embryo transfer. Data analysis revealed that PGT-A did not improve pregnancy outcome metrics in DE cycles, although there was a trend toward decreasing the SABR. There was a significant increase in IR with fresh cycles outperforming all frozen cycles. Overall, these results suggest that the benefits of performing PGT-A on embryos derived from young DEs may be limited and that there is an effect of the freezing process on pregnancy outcomes. These findings may provide useful insights into the science and practice of PGT-A across all of its applications."
Randomized trials using contemporary IVF and PGT techniques in patients with recurrent aneuploid pregnancy losses have not been performed. Although some observational studies have reported that RPL patients who underwent PGT-A had pregnancy rates comparable to those in control populations without RPL (e.g., women undergoing PGT-M for sex-linked disorders, IVF because of male factor infertility), the probability of subsequent live birth in patients with RPL without intervention is already high, approaching 70 percent; thus, these studies do not prove the benefit of PGT-A in management of RPL. It is theoretically possible that PGT-A may reduce the probability of miscarriage in patients with RPL due to aneuploidy and reduce the potential sequelae of recurrent miscarriage (uterine and emotional trauma); however, there is no evidence that PGT-A will increase the eventual take-home baby rate in these women.

In summary there is not supportive scientific evidence from high quality randomized controlled trials or observational trials that demonstrate and outcome benefit using PGT-A in the setting of recurrent pregnancy loss.  Therefore, this is an investigational service.
The requested service is not likely to be more beneficial at this time, as the literature is still evolving.