Infertility Tx denials in California external review

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: The patient requested reimbursement for the intrauterine insemination (IUI) procedure performed due to the patient’s diagnosis of infertility. A review of the records provided for review establishes that the patient has been unable to conceive through natural methods, which supports a diagnosis of female infertility. The patient’s history reflects that her follicle stimulating hormone (FSH) were elevated and her low antral count along with a family history of early menopause generated concern for the patient’s future ability to conceive. In addition, the records reflect that the patient’s husband’ semen analysis was abnormal. The patient’s records indicate that dietary changes were implemented, and natural family planning was attempted without success prior to undergoing an IUI procedure.

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: The patient has requested reimbursement and prospective authorization and coverage for intrauterine insemination, sperm washing for artificial insemination, and a fourth cycle of Clomid, and prospective intrauterine insemination, sperm washing for artificial insemination, and a fifth cycle of Clomid. According to the provider, this patient has a diagnosis of unexplained infertility. However, the records provided for review do not document that a complete work-up was performed. Specifically, there was no report of testing to evaluate the patient’s fallopian tubes and uterine cavity.

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