Female Infertility denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for in vitro fertilization (IVF) services: follicle puncture for oocyte retrieval, insemination of oocytes, sperm isolation; complex prep (eg Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis, oocyte identification from follicular fluid, ultrasonic guidance for aspiration of ova, imaging supervision and interpretation, the culture of oocyte(s) embryo(s) less than 4 days, cryopreservation; embryo, biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis) less than or equal to five embryos, and biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis) greater than five embryos Findings: The physician reviewer found that the patient clearly meets the guideline definition of infertili…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the medication regimen for estradiol 0.1 mg transdermal in preparation for the medicated frozen embryo transfer (regimen consisting of: Apply three patches to the abdomen and replace every three days, followed by two patches to the abdomen and replace every three days). The records indicate that this patient underwent frozen embryo transfer (FET) and preparation of the endometrium for implantation. In preparation for FET, estrogen can be given as an oral or a vaginal tablet, a transdermal patch, and a subcutaneous or intramuscular injection.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary female infertility. The submitted documentation reflects that the patient has attempted to become pregnant on two separate occasions by intrauterine insemination (IUI) in 2014 and 2016. These attempts included two IUI and nine IUI cycles, respectively. The patient has stated that she and her husband have been unable to conceive naturally and that IUI is the only thing that has worked for her.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet-rich plasma endometrial infusions. In this case, the patient had intrauterine adhesions that were lysed. She had an abnormal endometrial lining that was inhospitable for embryo implantation. The provider recommended platelet-rich plasma (PRP). Endometrial status is one of the main factors of pregnancy implantation failure. In women with a thin endometrium, PRP may be used as an intrauterine infusion to induce endometrial growth and increase clinical rates of pregnancies.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving female infertility, then check the rights and deadlines that apply to your plan.