Recurrent Pregnancy Loss: when insurers say no, reviewers often say yes

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: A patient has requested authorization and coverage for (1) chromosome analysis and/or (2) fibrillin-1 (FBN1) gene testing. Chromosomal microarray may be indicated following a workup for recurrent pregnancy loss that is non-diagnostic. In this case, the records document that the patient’s partner has undergone a workup for pregnancy loss which was nondiagnostic. Therefore, (1) chromosome analysis is likely to be more beneficial for evaluation of the patient’s condition than any available standard therapy. Per the submitted documentation, the records do not demonstrate a high enough score on the revised Ghent criteria, lens dislocation, or aortic root dilation, which would be indications for genetic testing for Marfan syndrome.

Where the denial was upheld

Physician 1: The patient is a 23-year-old female who has experienced repeated early pregnancy losses and then underwent evaluation and treatment for recurrent loss. Evaluation included a borderline positive ANA, no evidence of thyroid antibodies, no immune reaction to her partner’s antigens and heterozygosity of MTHFR. There is no evidence the patient was tested for Factor V Leiden mutation, prothrombin gene mutation, lupus anticoagulant, or anticardiolipin antibodies (ACA).The patient was treated with IVIG, Humira, Lovenox, and low dose aspirin for her most recent pregnancy, which was carried to term.Review of the submitted clinical information reveals no documentation of significant autoimmune disease or thrombophilia. The low positive ANA (which was intermittently negative) does not cause pregnancy loss or require treatment.

An enrollee’s medical history included recurrent pregnancy loss. The enrollee suffered miscarriages. She had operative hysteroscopy, polypectomy, and removal of possible products of conception and D&C (Dilation and Curettage). The enrollee’s provider indicated that due to the complex nature of the enrollee’s diagnosis, and the couple’s desire to become pregnant, the enrollee had the four laboratory services at issue performed to assess the cause of the enrollee’s recurrent pregnancy losses.Analysis and Findings: Three physician reviewers found that the American Society for Reproductive Medicine stated that routine testing of women with recurrent pregnancy loss (RPL) for inherited thrombophilias is not currently recommended.

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 recurrent pregnancy loss was denied, the published record says the denial is worth fighting.