Diagnosis: Infertility
Treatment: In Vitro Fertilization (IVF)
The insurer denied In Vitro Fertilization (IVF).
The health plan's determination is overturned.

The patient is a woman who is undergoing infertility treatment. At issue is the medical necessity of in vitro fertilization (IVF) in the absence of prior IUI (intrauterine insemination) cycles in this clinical scenario.

The requested IVF is medically necessary for this patient. With unexplained infertility, Cochrane Reviews found that when comparing "IUI in a stimulated cycle versus TI (timed intercourse) or expectant management in a natural cycle... There was no evidence of a difference in live birth rate between the two treatment groups. The evidence suggested that if the chance of a live birth in TI or expectant management in a natural cycle was assumed to be 24% [percent], the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%." Thus, making a requirement of IUI prior to IVF is not medically reasonable nor prudent.