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.

According to the documentation submitted, this is the case of a female patient with history of Hodgkin's lymphoma and Crohn's disease. She was seen by her Reproductive Endocrinologist for a consultation regarding oncofertility. She received chemotherapy in with added immunotherapy after four rounds. She was in remission. She felt a pelvic lump two weeks prior to arrival at the physician's office and a recurrence was discovered. The treatment plan included Rituximab + Nevo for the next three months and then a stem cell transplant (SCT) and a possible bone marrow transplant (BMT). The patient has two daughters and had no prior problems with infertility. The physician recommended embryo cryopreservation to preserve the patient's fertility prior to oncology treatments. Ovarian reserve and preconception bloodwork would be obtained. Intravenous fertilization (IVF) with intracytoplasmic sperm injection (ICSI) and preimplantation genetic testing for aneuploidy (PGT-A) would be done.    

PGT-A has not been established to increase the live birth rate. It is common knowledge the aneuploidy rate is relatively lower in this aged population (20-30% at most) and although PGT-A could be considered indicated for gender selection and to lower the miscarriage rates, it has not been found to be statistically beneficial in such young women desiring a live birth without gender specificity. The overall literature supports the effectiveness of women attempting IVF with PGT-A mostly due to the natural increase in aneuploidy rates. 

There is no literature to support an improved health outcome in such a young female patient, the appropriate regulatory bodies have not given final approval for PGT-A in this aged patient either, this patient is not a good candidate for PGT-A for the reasons noted above, and this is not the best treatment for this patient at this time. 

In conclusion, PGT-A (the requested service) has not been demonstrated to be more beneficial in this patient as opposed to freezing embryos without undergoing PGT-A (standard treatment). Finally, PGT-A is felt to be 98% accurate and is not a perfect test. False positive results have been documented in the literature and this is not a procedure without risk due to biopsy of the embryo(s) also.
    
In conclusion, PGT-A for this patient is considered investigational and has not been demonstrated to be beneficial as compared to IVF alone with cryopreservation. There is no improvement in health outcomes with the proposed codes, and they do not have final approval from the appropriate regulatory bodies for this diagnosis. The patient is not a good candidate for procedure codes 89290 and 89291. These codes 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 not 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.