Infertility denials in California external review
In the California DMHC record, independent physician reviewers decided 26 published external-review cases involving infertilityand overturned the plan’s denial in 50%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 17 | 70.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 11.1% |
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…
Nature of Statutory Criteria/Case Summary: An enrollee has requested a consultation with a fertility specialist for treatment of her possible egg retrieval and use of a surrogate. The physician reviewer found that according to Kuohung and Hornstein, “Age is an important factor affecting a woman’s fertility. The decrease in fecundability with aging is likely due to a decline in both the quantity and quality of the oocytes....The likelihood of a fertilized egg implanting is related to the age of the woman who produced the egg. Thus, the percentage of transfers resulting in live births for cycles using embryos from women's own eggs declines as women get older.” Moreover, Chung and Paulson state “Many women who delay childbearing may face infertility by the time they are ready to become pregnant.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen intravenous immunoglobulin (IVIG) 40 mg x one day, every week for three months. The records document that this patient has a diagnosis of infertility. Based on the submitted information, there is a lack of support for a diagnosis of recurrent pregnancy loss since the patient has a history of one spontaneous abortion. As noted in the medical literature, recurrent pregnancy loss is defined as at least two losses. In addition, the patient’s positive copy of the methylenetetrahydrofolate reductase (MTHFR) gene, does not affect her risk of thrombosis. Per the American College of Obstetricians and Gynecologists (ACOG), MTHFR gene mutation analysis is not recommended to determine a patient’s risk for pregnancy loss in this clinical setting.
Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for office medical services (89353). The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who presented for infertility services. This is a situation where the patient was unable to get pregnant because she was not in a current sexual relationship and was around the age limit of natural fertility. She underwent intrauterine inseminations and in vitro fertilization (IVF) in an attempt to conceive. The contention that these were not infertility treatments but instead were preconception/prenatal care is not supported by the records or the billing, and the services were in fact provided by an infertility clinic.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 infertility, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY