Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation services. Findings:  The physician reviewer found that egg retrieval and egg and/or embryo freezing (cryopreservation) are now a recognized option for women who have cancer who are undergoing treatment that can render them infertile in the future by being toxic to their ovaries/eggs. This option allows them to have children in the future. Technically, they are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of the chemotherapy. This procedure is not considered experimental or investigational and is a treatment that is appropriate to discuss and offer to such patients.A study noted: `Treatment of malignancy... may necessitate surgical resection of reproductive organs or administration of gonadotoxic chemotherapy or radiation therapy. This often leads to infertility, which is a major quality of life concern. With appropriate pretreatment planning and intervention, biologic parenthood is possible for many men and women who will lose reproductive function because of surgery or gonadotoxic treatment...Prior to initiating potentially gonadotoxic therapy, physicians should discuss the risk of treatment-induced infertility and possible interventions to preserve fertility.... Whenever possible, all patients with newly diagnosed cancer should meet with a reproductive endocrine and infertility specialist if fertility is a concern, preferably before treatment....Cryopreservation of embryos is a proven effective technique for preserving reproductive capacity.` This treatment is supported by the American Society of Reproductive Medicine. For patients such as this, when chemotherapy is anticipated to damage or destroy the woman's eggs, such a treatment is medically necessary. The American College of Obstetricians and Gynecologists also supports this treatment, noting: `Based on the current state of evidence, modern procedures to cryopreserve oocytes should no longer be considered experimental.... Oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies.` The Journal of Clinical Oncology notes that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting that `sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice.` Nationally recognized clinical guidelines support the use of fertility preservation services including cryopreservation in patients prior to undergoing treatment for cancer. In this case, the fertility preservation services were medically necessary, and the Health Plans decision should be overturned. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.