Diagnosis: Holt-Oram syndrome.
Treatment: In-vitro fertilization cycle with embryo biopsy (codes S4015, 89290, 89291, S0122, and S0128).

The insurer denied coverage for in-vitro fertilization cycle with embryo biopsy (codes S4015, 89290, 89291, S0122, and S0128).

The denial is upheld.

This is a female patient with a past medical history of Holt-Oram syndrome. After undergoing an embryo transfer, the patient was able to give birth to a healthy male baby. The patient returned to the fertility clinic because she was looking to expand her family. The quality and staging of her remaining cryopreserved embryo was reviewed during her consultation. According to her treating physician, the chances of conception are low due to the quality of the patient's current frozen embryo. Therefore, the patient is seeking another vaginal oocyte retrieval to conceive a healthy pregnancy.

The patient has no diagnosis of infertility. Currently, the patient has two euploid non-affected Holt-Oram syndrome embryos frozen. The patient would like to undergo more in-vitro fertilization cycles and bank more embryos for possible future use. There is no detail available about the frozen embryos. The provider wrote that these embryos were not of good quality but it is not clear what that means. By standard of care, only good embryos are biopsied. In addition, those embryos were tested, and were found to be euploid and not affected by the Holt-Oram syndrome. The patient had a healthy child using those embryos. So, it is questionable as to why these embryos were frozen if they were not of good quality.

According to the American Society for Reproductive Medicine (ASRM)'s recommendations about the number of embryos to transfer, it is advised given this patient's age, to transfer a single euploid embryo. The reason for that recommendation is because the odds of a successful cycle and live birth are very good estimated at more than 65%. As per medical record review, the aim of this patient is to conceive a healthy child (rather than to collect embryos) and considering there are two euploid embryos available, the odds of conception and live birth are excellent. Thus, additional in-vitro fertilization cycles are not medically necessary for this patient. If the patient does not conceive despite transfer of her embryos, then at that time, in-vitro fertilization cycle may be necessary. If the transfer of these embryos fails, this will only lead to delay of 2-3 months and such a delay should not significantly affect this patient's ovarian reserve.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for requested in-vitro fertilization cycle with embryo biopsy (codes S4015, 89290, 89291, S0122, and S0128) should be upheld. The medical necessity is not substantiated.