Our DD and SIL have been dealing with infertility issues–but are now expecting-- Woo Hoo!
As many know, infertility treatment is Expensive! They are now trying to get their insurance to pay up for the egg storage…but keep getting denied by United Healthcare. Any CC experts here that can point out what we might be missing??
"Exclusions:
Reproduction:
The following treatment related services:
-Cyro preservation and other related forms of reproductive materials EXCEPT
as described under Infertility Services."
INFERTILITY SERVICES
Therapeutic services for the treatment of Infertility when provided by or under the direction
of a Physician. BENEFITS under this section are limited to the following procedures:
Assisted reproductive technologies (ART).
Frozen Embryo transfer cycle including the associated cryopreservation and storage of
embryos.
This is the response from the Insurance company when DD appealed (complete with her Dr’s signed letter of necessity.)
"After reviewing your request, including all medical information we received, we determined that this service(s) is not covered under your medical benefit plan. Per your Benefit Plan, under the section ‘Exclusions: what the medical plan will not cover,’ subsection ‘Reproduction’:
The following Infertility treatment-related services:
Cryo-preservation and other forms of preservation of reproductive materials except as described under Infertility services."
(emphasis added was DD’s)
What are we missing? They are citing back the same sentence DD is citing…without even reading.
Ugh. United Healthcare has been in the news lately because they are denying claims right and left. Just have your D keep appealing. She should have her benefits director involved, if she has a job that actually has a benefits director - I worked for a group insurance consultant for awhile, and the benefits people I dealt with were very proactive in helping their employees. If she doesn’t get anywhere, she could contact her state’s insurance ombudsman.
FWIW, my GD’s amazing pediatric group just notified D that they will no longer accept UHC effective 1/1/24. D doesn’t know why, but I suspect that the insurance company may be denying too many claims. It’s a strain on medical billing departments. Unfortunately, the other good local pediatric group doesn’t take UHC anymore, either. It’s not a huge player in the area, but it’s the only insurance available through D’s employer & through SIL’s employer.
My daughter has infertility coverage as dictated by the state she works in and has health insurance through.
Unfortunately getting a physician and the insurance company to work together to have her treatment covered was another story. Time was the issue, she had to pay out of pocket.
I have no answers but am sympathetic to the issues with infertility treatments.
She should resubmit, quoting back to them their own website’s words regarding the Frozen Embryo…, saying that this IS covered under infertility services.
She should also contact her employer’s benefits department, and the state’s insurance ombudsman. And as a last resort, her area’s consumer protection news reporter. She is entitled to this being covered.
She’s done three rounds of quoting/bolding/underscoring from their website…and keeps getting the denial above. Very frustrated with the lack of reading comprehension at UHC. Working on steps you suggested…thanks.
Clearly she has coverage. This is embarrassing for UHC.
Ideas:
Has she spoken with someone at UHC live on the phone or in person? She should call the last medical director who denied the appeal to start with. Talk with that person’s boss if this doesn’t get resolved. Continue going up the food chain which may entail moving to national rather than regional staffers.
If her insurance is thru her employer, has she spoken with her employer benefits person so they can help advocate for her? Each employer has a sales person who probably does not want to lose the business and they also have access to a customer service team.
Has she called all of UHC’s complaint numbers? They are organized by line of business so start with whatever type of policy she has.
She might tweet the information, including images of the denial and policy clearly showing she has the benefit at the senior execs and the UHC customer service account(s).
I concur with the recs to get the state insurance commission involved.
@kelsmom, Years ago, our pediatric group severed relations with our insurer (calendar year coverage) in April, when their contract ended. The insurer was switching from fee-for-service to a per capita model which didn’t make fiscal sense for the pediatric practice.
Apparently, the complaints brought to the FEHB about this mid-contract shift caused the insurer to continue fee-for-service for the existing patients in the plan until the end of the year.
Not really a solution for your DD. I hope they can find an adequate provider.
Ugh United. At least they’re receiving your D’s claims. Back when I had a similar issue they kept “not receiving” my letters or my doctor’s letters.
I started sending them overnight signature-required. They tried “not receiving” more than one of those too, until I responded with “Joe in receiving signed for it.”
Also my state insurance agency couldn’t do anything with ERISA plans, which I discovered after filing a complaint about United “not receiving” my letters.
This - ask for the Appeals and Grievances department (they might call it something slightly different) and talk to someone, get names, case numbers, etc. Follow up in writing documenting the conversation and what you understood from it.
Escalating to a legislator or other governing body is good too if this doesn’t work but those paths will ask you for the details of who you’ve been in contact with and dates, documents, etc.
Tied with the egg/embryo issue is medical coding. My doctor had a fantastic admin person who knew how to code services to get them covered. If she just put in ‘ultrasound’ it wouldn’t be covered (this was a long time ago) but if the put in ‘habitual aborter’ (yes, a horrible name for multiple miscarriages) it was covered.
It’s clear that egg storage is not covered, only embryo storage is covered. That is your problem if as you state they are seeking approval for egg storage.
The way I read it the IVF coverage is intended to includes the storage of additional embryos generated as the byproduct of an initial IVF cycle to be used in a subsequent frozen embryo cycle. Whether you could freeze embryos without doing IVF at the time is less clear (I think it’s probably covered) but that would be unusual since fresh transfers are more likely to be successful than frozen ones so you usually do both.
Why would they as a couple even do egg storage since historically it has had lower success rates than embryo storage? I guess it’s cheaper but it sounds strange for a couple to contemplate this.
Embryos. She has 7. 2 are good choices without the genetic mutation she has. Both boys. She was hoping for one good girl embryo but that didn’t happen.
OP here… circling back after travel/wedding/out of town guests, etc.
20 days ago, I tweeted to United Health…and surprisingly got a reply within an hour.
Asked for my D’s name/phone and when would be convenient to contact. UHC contacted her immediately…but her issue wasn’t that person’s department. Here we go again!
They finally got her the right department the next day. D was told that the egg storage wasn’t the issue…it was that the pre-authorization was denied. Ummm…timing is key with fertility procedures. At least that person agreed with my D that egg storage was covered. And the claim wasn’t denied …just the pre-authorization.
(Side note: one of the frustrating issues with appealing to UHC is that emails aren’t allowed…one must send a letter or fax for a paper trail. And one cannot deal with the same person on issues…ugh.)
My tenacious D was not to let this go…because now she’s ticked and doesn’t want to give up on $2K. And I don’t understand all of the minutiae but…D got ahold of someone who discovered the procedure code was listed on a different authorization number…which was the authorization number that was denied.
So…as of now, D’s doctor is re-billing under the new authorization code…and apparently this will solve issue. (Yeah, this is above my pay grade).
D & SIL are on their babymoon right now (why didn’t I think of this 33 years ago???) and are hoping to come back to a resolution. Fingers crossed! Thanks for all of your suggestions…hoping this will be the end of it!
As I said above, a medical biller in the doctor’s office who knows her stuff is gold. Attention to detail, correct billing codes, following up on denials…all very important and unfortunately very little the patient can do about it but pray (and keep good notes).