Insurance coverage for RPL testing

sunflwra

HI ladies!  Wondering what other's experience has been here since I know many of us have had the RPL testing done. Apparently my insurance provider has decided that they won't cover the MTHFR blood test.  There were generic notes about it either being experimental or unproven for my diagnosis (habitual aborter- don't you love seeing that in writing).  I've called them and started an appeal.  My husband said there are many insurance companies that will put a blanket denial out on certain claims, but when you actually contest it, it gets covered.

I believe this test is a pretty common one amongst the RPL panel, so I can't see how it would be considered experimental or unreasonable for my diagnosis if most OBs test for it when losses happen.  Just wondering what others experience has been with getting coverage on some of the RPL testing.  I'm with Cigna Open Access. My phone based appeal really didn't require anything, so I'll see where that gets me and if it's denied again, I'll put something more formal together in writing.  Thanks ladies!

ellebelle2384

I'm surprised they didn't cover it but I bet your H is right about them just putting a blanket denial out there.  Ours was covered but I still had to pay a large chunk of change for the RPL panel since I have a high deductible plan.  Hope you can get it taken care of without too much hassle!  And ((hugs)) for seeing that diagnosis in writing.  I hate seeing it on all my paperwork, it makes things so much worse.

Km380

We had Aetna when we did the testing and most of it was covered. We've since changed to Cigna and generally everything costs more. But the RE office also told me they have to code things carefully to get them covered. I forget but it was either not referencing infertility or not referencing multiple losses. You could check with the RE office if there is a different way to submit. GL!

alleycat39

Km380 said:

We had Aetna when we did the testing and most of it was covered. We've since changed to Cigna and generally everything costs more. But the RE office also told me they have to code things carefully to get them covered. I forget but it was either not referencing infertility or not referencing multiple losses. You could check with the RE office if there is a different way to submit. GL!

I have Aetna and they did not cover my most recent RPL panel which consisted of MTHFR, Factor V and a few others I forget. They called it "experimental" and I was left with a $1200 bill. I sent in a written appeal but haven't heard back. I'll let you know if I make any progress and if so, will gladly send you the letter i sent. This all totally sucks.

sunflwra

Thanks ladies.  These were run via my OB, so not sure if that will make a difference in whether they are paid or not (versus being run by a specialist).  I asked her up front how insurance typically did with coverage and she said that there are usually no issues getting the karyotyping covered but the RPL testing is a crap shoot.  I didn't even bother calling the insurance company up front because I knew we were going to do it no matter what.  I guess we'll see how they do on the appeal and, if they deny it, I'll request more specific reasoning so that I can draft something to them.  Thankfully the balance is only about $400 so I knew it could be much worse.  Just freaking ridiculous!

Km380

@alleycat39 wow $1200! I'm sorry it cost so much. I hope your appeal gets it covered

DenaMaree

I didn't even think about insurance not covering the testing! Is there a different code that they could use to get the billing through. We had it done and it was all covered. I'm so glad we did as I learned I do in fact have compound homozygous MTHFR. Good luck!!