Fertility Preservation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fertility preservation services. Findings: The physician reviewer found that egg retrieval and egg and/or embryo freezing (cryopreservation) are now a recognized option for women who have cancer who are undergoing treatment that can render them infertile in the future by being toxic to their ovaries/eggs. This option allows them to have children in the future. Technically, they are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of the chemotherapy. This procedure is not considered experimental or investigational and is a treatment that is appropriate to discuss and offer to such patients.A study noted: `Treatment of malignancy...

Nature of Statutory Criteria/Case Summary: Case Summary: A patient who was diagnosed with an unresectable Stage 2 perihilar cholangiocarcinoma, bile duct cancer. The treatment discussed includes possible chemotherapy with radiation and evaluation for liver transplant. The patient began evaluation for egg preservation and underwent in vitro fertilization, specifically ovarian preservation in which seven mature oocytes were successfully retrieved and stored.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for fertility preservation services (stimulation and removal of her oocytes, inseminating the oocytes, and the cryopreservation of the embryo). Researchers found that fertility preservation in both female and male oncological patients is now possible and should be integrated as part of the oncological healthcare. In this case, the patient had negative margins from the initial excisional procedure. According to medical literature, the rates of residual AIS, recurrent AIS, and concomitant or subsequent invasive adenocarcinoma in this clinical setting are approximately 2.6%, 20%, and less than one percent, respectively.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for embryo storage services (CPT 89342). Based on the available clinical documentation, the patient has a history of infertility, Hashimoto’s thyroiditis, and uterine leiomyoma. The patient underwent in vitro fertilization (IVF) procedures. Embryo storage services are a component of IVF treatment. The patient has a history of uterine fibroids on imaging. Her most recent hysteroscopic assessment revealed a normal intrauterine cavity indicating no submucosal component to her fibroids. There is a lack of data in the peer-reviewed medical literature supporting an indication for IVF in this clinical setting. Embryo storage services are not a standard therapy in the treatment of uterine fibroids.

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 Fertility Preservation, then check the rights and deadlines that apply to your plan.