Fertility Preservation denials: what the review data shows
Independent reviewers have decided 15 published cases where an insurer denied Fertility Preservation — and they overturned the insurer 80% of the time. A denial for Fertility Preservation is a starting position, not a final answer.
Conditions behind fertility preservation denials
| Category | Decisions | Overturned |
|---|---|---|
| Breast | 6 | 100% |
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.
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 treatment generally, not any individual case.
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Fertility Preservationwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY