In(not-so-sure)ance

(I’m in the 2ww again. My OPK showed ovulation a couple days earlier than expected. Maybe it’s because AF started so late last month? I wouldn’t know since a late AF is so rare for me. At any rate, we had sex 5 times in the 6 days surrounding ovulation…. that *should* do the trick, right?)

Here’s another installment of our fertility story. Last I wrote, we had finally gotten the DNA samples together to start the process of PGD, which is how our embryos would be tested for Fragile X.

Our next hurdle: Insurance!

We’re fortunate to live in a state where fertility treatments are covered by insurance, but they certainly don’t make it easy. Before the RE could submit the claim, we had to enroll with the Infertility Hotline. The phone rep listened to my sob story, looked at my poor hormone test results, declared me to be eligible for benefits and then spent 30 minutes enrolling me in the fertility program.

We celebrated that IVF was covered, yay!

Then PGD was officially approved, yay! Here’s how the PGD claims process was explained:

1) Pay $3850 out-of-pocket directly to the genetics lab for PGD
2) Wait 4 months while the DNA samples are grown and analyzed
3) Complete IVF egg retrieval, fertilization and PGD testing
4) Submit claim for reimbursement with the necessary “Date of Service”
5) Receive check.

If you’re thinking that’s a shady way to do business, you’re right. After we completed steps 1 & 2, our IVF claim was denied. Why? Because we weren’t considered “infertile.” And if we were, we’d be required to do IUI’s first. Try doing PGD on that.

Never mind the chunk of change and 4 months time lost. We were staring down the barrel of about $20K for a single cycle of IVF. What’s more, our RE wasn’t even sure that my Fragile-X-Carrier ovaries would even respond to the hormones; often they don’t.

So I wrote an appeal letter. It had four main components:

1) You already approved PGD, which is impossible without IVF
2) Our IVF claim isn’t for infertility; it’s for PGD
3) IVF with PGD will be much cheaper in the long run than caring for a special needs child
4) Denying this claim feels like an insurance loophole.

My therapist told me to use #4 because it hints at trouble that the company would want to avoid.

Surprisingly, we got a reversal of our denial within two days!

Fast forward a couple months. After completing our first IVF cycle with PGD, we submitted our PGD reimbursement claim. Guess what? DENIED! Because we didn’t use the exact genetics lab they *claim* they specified.

One day I’ll get around to appealing that….

Advertisements

4 thoughts on “In(not-so-sure)ance

  1. Hi, we were recently denied fertility medicine coverage because of PGD diagnosis code. We’re considering an appeal. Since your appeal won, would you mind sharing the letter you wrote or more detail that would help us writing ours? I’d really appreciate it! It’s hard to know where to start! I couldn’t find your email address on here or I would have wrote a PM. Thank you!!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s