Female Infertility: when insurers say no, reviewers often say yes
In 21 published external-review decisions involving female infertility, independent physician reviewers overturned the insurer’s denial 57.1% of the time.
Most-fought treatments for female infertility
| Category | Decisions | Overturned |
|---|---|---|
| Infertility Tx | 10 | 60% |
| SCP Consult Refer | 3 | 66.7% |
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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for female infertility was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY