Diagnosis: Infertility.
Treatment: Fertility services (In-vitro fertilization ([IVF]).
The insurer denied fertility services (In-vitro fertilization ([IVF]).
The denial is upheld.

The patient is an adult female gravida one, para zero, abortion one (G1 P0 Ab1) - with a history of infertility. The patient underwent in-vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) was performed. The Health Plan has denied coverage due to lack of medical necessity.

The proposed treatment was not medically necessary.

The medical records and medical literature were thoroughly reviewed. There is no evidence of a specific diagnosis of the cause of the infertility. The American Society for Reproductive Medicine, in its Practice Committee Opinion, states: "Oocytes retrieved from older women have been theorized to have structural defects of the zona pellucida or cytoplasm that might reduce the fertilization rate with conventional insemination. In practice, oocyte fertilization rates in women older than 35 years using conventional insemination are similar to the fertilization rates of younger women. One retrospective study attempted to address this question, demonstrating similar fertilization rates, clinical pregnancy rates, and livebirth rates between women who had oocytes fertilized by conventional fertilization and those who had ICSI...ICSI for advanced maternal age does not improve live birth outcomes...In cases without male factor infertility or a history of prior fertilization failure, the routine use of ICSI for all oocytes is not supported by the available evidence".

The American Society for Reproductive Medicine sets guidelines that are the standard of care for the treatment of infertility patients. In its Practice Committee Opinion, the American Society for Reproductive Medicine states that, unless there is a significantly abnormal semen analysis, the use of intracytoplasmic sperm injection (ICSI) when doing in-vitro fertilization does not result in better pregnancy rates. Therefore, the standard of care does not support in-vitro fertilization via intracytoplasmic sperm injection (ICSI), and it is not medically necessary.