Insurance companies increase restrictions on infertility coverage

Because infertility has not been considered a “disease” for the longest time, and by many institutions till today, private insurance coverage of infertility services has been a challenge since the advent of IVF. As private insurance is only mandated to cover disease states, this distinction was legal grounds for refusing the coverage of infertility treatments. Further support came from the federal government also refusing coverage under federal health insurance programs, Medicaid and Medicare.

All of this started to change in the 1990s when a small number of states, starting with Massachusetts and Illinois, passed laws that mandated the coverage of infertility services, including IVF, under standard health plans. While extent of coverage varied between states, these state laws offered for the first-time access to IVF to broad swaths of the population. In parallel, infertility was by the courts recognized as a disability, setting the stage for the legal argument that withholding insurance coverage for infertility represented a breach of the Americans with Disability Act. Employers and private insurance companies, therefore, started offering infertility coverage, though at different levels, with some covering only diagnostics, others offering lower levels of treatments up to IVF and a small minority offering a comprehensive package including 3-4 IVF cycles.

But as IVF coverage seemingly increased, insurance companies also started interfering in the practice of IVF by mandating which patients could or could not be treated (some insurance companies, for example, restricted treatment based on age and/or FSH levels) and how patients had to be treated (for example, before a patient could be offered IVF, a patient had to have failed 3 IUI cycles).

These practice restrictions, as insurance companies uniformly have been representing to public and treating physicians, were based on “best scientific evidence,” usually collected by paid medical consultants and, therefore, were claimed to be motivated only by a desire for best patient care. That they may be motivated by containing costs to the insurance companies, is usually strenuously denied.

The control insurance companies exercise over IVF practice has over the years constantly increased. We recently witnessed one of the most bizarre cases ever, when a major insurance company approved a patient’s IVF cycle but refused coverage for the proposed use of intracytoplasmic sperm injection (ICSI), which represents just a minute fraction of total IVF cycle costs. The patient appealed the decision and the insurance company set up a “peer-to-peer” telephone conference between a CHR physician and a medical director at the insurance company.

This medical director turned out to be anything but a “peer.” He was not a fertility specialist, not even an Obstetrician-Gynecologist. When the CHR physician explained the rational for ICSI, that the male demonstrated sub-fertile sperm morphology at 7% Kruger criteria and that maximal fertilization was essential since the 45-year-old female patient, likely, would produce only very few eggs, the medical director’s only response was that, based on “best evidence” the company allows (i.e., pays for) ICSI only once sperm morphology is in infertile range, below 4% Kruger criteria. CHR’s physician’s retort that this may make sense in a young woman but does not in a 45-year-old woman, fell on deaf ears.

What makes this case so extraordinary and such a good example for the stupidity of the system, is the willingness of the insurance company to risk the whole IVF cycle (if fertilization fails) at a cost of thousands of dollars, to save a few hundred by refusing to pay for ICSI. Moreover, think about all the costs the insurance company incurs in administrating all this bureaucratic morass, including the hiring of medical directors who prefer to shuffle papers to practicing medicine.

Because of practice restrictions like this (which we, as in this case, simply, consider bad medicine), and the increasing administrative overhead required from physician providers to manage the demands of many insurance companies (nobody, for example, paid CHR for all the time staff dedicated to this appeals process), CHR, already a good number of years ago, discontinued relationships with most insurance companies. Even the few contractural relationships we still maintain are, however, increasingly strained, more difficult and restrictive, as this example demonstrates. Considering that the nation is amid intense discussions on how our current health care system can and must be improved, we here at CHR wonder whether the private insurance market is really the best solution, at least for infertility.

This is a part of the April 2017 CHR VOICE.