Oocyte Cryopreservation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services for treatment of the enrollee’s risk for iatrogenic infertility secondary to breast cancer treatment. Findings: The physician reviewer found that female patients undergoing chemotherapy, surgery and/or radiation treatment for cancer may experience serious gonadotoxicity. The extent of ovarian damage is dependent on the type of treatment as well as the age at the time of treatment. As the treatments for malignancies in females continue to improve their survival rates, increasing numbers of patients may seek preservation of their fertility. Reducing the radiation dose to the ovary by shielding or surgically removing the ovaries from the field of radiation may preserve ovarian function.

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

Findings: The physician reviewer found that a patient has requested authorization and coverage for oocyte cryopreservation, including reproductive endocrinology visits; ovarian stimulation medications (gonadotropins), gonadotropin-releasing hormone (GnRH) antagonist/agonist, ovulation trigger [human chorionic gonadotropin (hCG) or GnRH-analogue]; monitoring labs and ultrasounds; transvaginal oocyte retrieval with anesthesia; embryology services (oocyte identification vitrification/cryopreservation); initial storage (12 months); related laboratory fees and infection screening. There is a lack of scientific data showing that certain medications cause iatrogenic infertility and that other medications affects fertility in men or women without diabetes. Per the medical records, the patient has diagnoses of immunoglobulin A (IgA) nephropathy and chronic kidney disease.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested cryopreservation of oocytes for treatment of the enrollee's medical condition. Two physician reviewers found that upon review of the submitted documentation, it is not clear that the patient has expressed a desire to procreate in the future and/or to preserve his fertility via cryopreservation of oocytes. While the clinical documentation provided discusses the patient’s desire to transition to the male gender by pursuing hormonal therapy and breast removal surgery, there is no evidence the patient has discussed the issue of fertility preservation with his providers.

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