Fertility Coverage or Bust for our Patients

The average cost of a cycle of IVF, including medications hovers around $15-16,000 (all costs). Cost is obviously a barrier to IVF which is unfortunate as it provides the highest chance of live birth. Approximately 50% of the patients I see have infertility treatment coverage. This is due to our close proximity to Illinois which has one of the more comprehensive fertility mandates in the US.

Many times insurance companies that cover IVF will not cover it unless there is a "medical necessity." Oftentimes we write letters and talk on the phone with insurance company MDs fighting for our patients to have coverage for IVF. This usually involves multiple levels of written letters, peer to peer phone conversations and in-person testimonies.

Sometimes we are successful and sometimes we come up short. Man, it feels good when we get a claim approved! I wanted to share a recent success story emphasizing that persistence pays off.

I saw "Brenda" (name changed) who is 40 years old and had been trying to conceive for year. Her husband was being deployed for one year. He banked sperm and had it shipped to us. Fortunately, Brenda had IVF coverage but it would not kick in until she tried other fertility treatments like artificial insemination OR had a medical necessity to move straight to IVF.

The sperm sample that was banked was not adequate for IUI and would only be good for IVF. She had no option and opted to pay for IVF out-of-pocket. While skeptical, she knew that I would go through the appeals process but she couldn't afford to wait so she prepared for IVF out of pocket. What follows is the process of appeal:

1) My 1st Written Appeal

Brenda is a 40 yo G0 with one year of infertility. Her husband has been deployed to Afghanistan and the sample that he produced was very poor and speaks to a probably underlying male factor infertility that is only amenable to IVF-ICSI. Therefore this is a an appeal for medical necessity. At best, Brenda's husband will return in one year at which time she will be 41 years old and in that interval alone her likely of success with IVF would decline by 50%. Even if the husband were available, intrauterine inseminations would not be suitable with his semen parameters. IVF with ICSI is Brenda's only option for pregnancy. I hope this letter of medical necessity finds you well.

2) Peer-to-Peer

I had a conversation with a non-reproductive medicine (i.e like asking a plumber to give approval on electrical work in a house) specialist. He immediately told me that he could not reverse the decision, but recommended a second level appeal.

3) My 2nd Appeal (quoting literature)

I am seeking a second level review of the need for coverage for IVF-ICSI based on medical necessity for my patient. The first level review refutes the diagnosis of male factor infertility, however there are additional points relevant to the patient's history that are being overlooked.

As per the definition of medical necessity "medically necessary means those services...[that] are determined by the health plan to be necessary to meet your health needs, improve physiologic function and required for a reason other than improving appearance."

The section goes on to say that [these services should be] "rendered in the most cost efficient manner and setting appropriate for the delivery of health service." and "consistent in type, frequency and duration of treatment with scientifically based guidelines"

In response: Brenda is a 40 yo G0 who has been attempting pregnancy for over one year which meets the definition of infertility. She is not looking to improve her appearance but to build her family in the absence of her husband who is a serviceman. Physiologically - based on her age - her fecundability (i.e likelihood of pregnancy per month) is <5%. Published data would suggest that her likelihood of pregnancy after 3-6 cycles of ovulation induction IUI is 6.5% (PMID: 18191842), whereas her likelihood of pregnancy were she to proceed immediately to IVF are at least 20-49% (PMID: 24796764)  

In summary, Brenda has infertility but is not eligible to do any treatments like IUI because her husband is on at least a one year tour of military service overseas. When he returns she will be 41, and she cannot afford to delay fertility treatments. Before her husband left, he banked a sample and while inadequately collected it is not suitable for IUI, only IVF. Were her husband available I would still recommend IVF as the first line treatment for this couple based on the data I cite. I hope that you will reconsider your decision and provide coverage for this serviceman and his wife. 

Thanks, again, for the opportunity to appeal.

 
4) Hearing by insurance company

The second letter granted me an opportunity to testify on Brenda's behalf in front of insurance company appeals handlers. When I called to set up my time to testify, I learned that the meeting had been canceled because the group had approved the appeal!!!

5) Brenda's letter to me after getting the approval

I received a call today explaining that my insurance company has agreed to pay for my IVF treatment. Needless to say this was one of the best phone calls I've yet to receive. I make $40,000/year and out of pocket payment was a huge stress considering its over 1/4 of my salary. I would have paid it without hesitation because the possibility of a baby is worth any amount to us; I'm ever so grateful for all the help.  I want to thank you for fighting the "good fight" for me when I didn't even know that it was option. I thought if the insurance company refused to pay that I didn't have any other choice. I want to thank you for your diligence in pursuing my claim. Your support means more to me than I could possibly express; from the bottom of my heart - Thank You!!!

Fertility treatments are not a guarantee but they are remarkably more efficient today than just 5-10 years ago. The Affordable Care Act's effect on fertility coverage is unknown at this time. State mandates will be in place through 2015, but its unclear what could happen thereafter. In the meantime, we will continue to advocate for our patient's as they work to build their family.