Diagnosis: Polycystic Ovarian Syndrome (PCOS).
Treatment: Clomiphene Tab (tablets) 50 milligrams (mg).

The insurer denied coverage for Clomiphene Tab (tablets) 50 milligrams (mg).
The denial is overturned.

According to the documentation submitted, this is a female with a history of secondary anovulatory infertility and polycystic ovarian syndrome (PCOS). She had a telemedicine visit with the Obstetrician/Gynecologist (OBGYN). The physician discussed treatment options including continuing Clomid or referral to a Reproductive Endocrinologist for possible intrauterine insemination (IUI).

Clomid has been the most widely used treatment for fertility enhancement for the past years. The best candidates for Clomid are women with polycystic ovary syndrome (PCOS). Clomid is initially begun on cycle day 3, 4, or 5 at a dose of 50 mg (milligram) daily for five days. If ovulation does not occur in the first cycle of treatment, the dose is increased to 100 mg. Thereafter, the dose is increased by increments of 50 mg to a maximum daily dose of 150 mg until ovulation is achieved. The couple is advised to have intercourse every other day for one week beginning five days after the last day of medication.

Clomid does not appear to be associated with adverse perinatal outcomes or an increased risk of congenital malformations. This patient has PCOS, she does not ovulate by herself. To conceive she needs to have her ovaries stimulated. Clomid is used routinely and is very effective for that purpose. Clomid was successful in helping this patient conceive once. Continuation of that therapy is medically necessary.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Clomiphene Tab 50 milligrams (mg) is considered medically necessary for this patient. The insurer's denial of coverage for Clomiphene Tab 50 milligrams (mg) is overturned. Medical Necessity is substantiated.