Who has had to fight with insurance? Help.

liz4paws · June 2013

We learned earlier this year that we have a new $10k lifetime max infertility benefit. We never had it before this year, and let me start by saying I am incredibly grateful for it and do not take this for granted. My heart hurts for those of you who have no coverage, because I do know what that is like and its terrible.

This question is for those of you who do have fertility coverage and have had to fight for IVF/FET coverage.

My clinic submitted preauthorization for our upcoming FET. They denied it due to two reasons:

1) No proof that we have attempted to achieve pregnancy for one year with unprotected sex.

2) We needed to attempt IUI three times with failure.

So for the first issue, how in the hell does one prove they've had unprotected sex for a year? Us achieving pregnancy through unprotected sex has been going on for far longer than a year, and I have a better chance of growing an elephant out of my forehead.

For the second issue. We did try IUI once. It was a failure, just as my RE knew it would be. But we gave it a shot in 2011 just to say we did. We have SEVERE MFI and SEVERE DOR. I mean, we are at donor embryos for crying out loud. I didn't respond to 600iu of stims. DH produced like 400k sperm for our IUI.

Did anyone else run into these two requirements? Were you able to prove whatever was necessary to bypass the three IUIs and go straight to IVF (or in my case, FET)? What happened? What would you do if you were me?

Any insight/advice is appreciated. Thanks!

NYCGal276 · June 2013

Liz - your siggy says that you had your first IUI in 2011 - can't you say that during the time of that treatment you clearly were NOT on bcp?

liz4paws · June 2013

NYCGal276:
Liz - your siggy says that you had your first IUI in 2011 - can't you say that during the time of that treatment you clearly were NOT on bcp?

Yes, which is true. But is my word proof? I guess that my question. I hope it's good enough.

I'm most concerned about their second requirement, how we can bypass this "three IUI requirement" nonsense?

NYCGal276 · June 2013

weeklyplanner:
Maybe a letter from your RE stating you have been trying for over a year and that 3 IUIs would not work given your situation? I'm not really sure how you prove you've been having sex. Stupid insurance companies!

I think you need to send your insurance company proof of your previous treatment and have your RE write a strongly worded letter indicating that IUI will not rear a positive outcome. The insurance companies also have doctors who review the claims - it's just about having a strong enough argument to help them understand.

WindyCity33 · June 2013

liz4paws:
1) No proof that we have attempted to achieve pregnancy for one year with unprotected sex.
So for the first issue, how in the hell does one prove they've had unprotected sex for a year? Us achieving pregnancy through unprotected sex has been going on for far longer than a year, and I have a better chance of growing an elephant out of my forehead.

I don't really have any advice but I just wanted to let you know that I love you. I hope that you're able to grow that elephant and have the ins. company back off. There has to be a waiver of some sort considering your history. I know logic is tossed out the window with most insurance companies but FX they get it together!

kjf114 · June 2013

You have proof with your IUI attempt in 2011-- that's still cleary almost 3 years. I would submit the proof from your gyno or re regarding that. 2nd issue I'm sorry your facing that.. my insurance saw severe MFI and allowed us to skip IUI due to it. My RE's nurse said if they denied they could write a letter to say it higher chance of pregnancy with IVF versus IUI. good luck I hope it doesn't take that long to get you going!

DoublePortion · June 2013

I would think the canceled IVF would exclude you from 3 IUIs or at least the 2 you haven't done. If you had zero response to stims and couldn't even complete an IVF cycle then multiple IUIs would be a waste of time and money!

Malvagia · June 2013

Can you ask your insurance company what they consider to be proof that you've had unprotected sex for one year or what they've accepted as proof in the past.

I don't know why an insurance company would think that people would want to under go fertility treatments before knowing they had issues.

liz4paws · June 2013

Malvagia:
Can you ask your insurance company what they consider to be proof that you've had unprotected sex for one year or what they've accepted as proof in the past.
I don't know why an insurance company would think that people would want to under go fertility treatments before knowing they had issues.

Totally!

Yeah, I was getting bored with sex with DH. So I thought it might be fun to ask a bunch of strangers to start prodding at my lady parts with a camera every few days, you know...just for fun. Oh and my butt cheeks were feeling just a little too comfy back there, so I thought I might need to shove a giant PIO needle into it every night after dinner. WTH is wrong with these companies? I'd like to think no one would intentionally sign up for this stuff if they didn't need it.

liz4paws · June 2013

Thanks for the info and advice ladies. I just emailed my RE asking her to write a letter stating we are ineligible for IUIs. Hopefully she will, and hopefully it's enough and HOPEFULLY we can just get this donor embryo cycle on the road already!

If not, I will threaten to grow said elephant out of said forehead.

NJHopeful · June 2013

So sorry to hear this. My insurance covers absolutely nothing.... it's frustrating and a crime!

liz4paws · June 2013

NJHopeful:
So sorry to hear this. My insurance covers absolutely nothing.... it's frustrating and a crime!

I'm so sorry. You're 100% right, it's awful. The financial aspect can be almost harder (if not harder at times) than the process itself. *hugs*

Km672 · June 2013

Uuuuugggggggg!!!
I have been there and it is beyond annoying!!!! A lot of my stress comes from constantly fighting with my insurance!!

I agree, your RE needs to go to bat for you. Seriously, several times it has taken our RE to get on the phone with an actual medical professional...

Btw, what a freaking concept, medical professionals making medical insurance approvals!

Best of luck, Liz. I've been there many many times and in the end, we were always approved.

liz4paws · June 2013

Km672:
Uuuuugggggggg!!! I have been there and it is beyond annoying!!!! A lot of my stress comes from constantly fighting with my insurance!! I agree, your RE needs to go to bat for you. Seriously, several times it has taken our RE to get on the phone with an actual medical professional... Btw, what a freaking concept, medical professionals making medical insurance approvals! Best of luck, Liz. I've been there many many times and in the end, we were always approved.

My RE replied to me today saying she was all over this appeal and she will work through it and write a letter or whatever is necessary to get it through. I believe her, let's cross our fingers it's quick! How long did your appeals for preauthorization usually take?

PS: I'm curious, does your insurance company name rhyme with Moonited Health care? They have been AWFUL.

Km672 · June 2013

Lol no... I have a different insurance. They were approved immediately after my RE got on the phone with them.. Best of luck this happens quickly for you, it is so stressful

MrsSJE2011 · June 2013

Been down this road all too much! As much as a blessing insurance coverage is (ie we would not be able to pursue ART at all if not for living/working in a mandated state), it certainly adds another level of stress. Although I have a different insurance company (rhymes with Farvard Hilgrim) my best suggestion is to have them send you a copy of their infertility criteria/policy. I was actually able to find my insurance company's via google. There should be cut offs (ie SA results, AMH etc) that will allow you to bypass the "try three before you move on" rule. We only had to do 2 IUIs due to DH's SA numbers. Also, the one year of trying criteria is based on your RE's medical notes submitted. Since it has been so long for you, your RE may not have even put it in the notes. HTH! We are under our review for FET approval right now.....

MrsSJE2011 · June 2013

MrsSJE2011:
Been down this road all too much! As much as a blessing insurance coverage is (ie we would not be able to pursue ART at all if not for living/working in a mandated state), it certainly adds another level of stress. Although I have a different insurance company (rhymes with Farvard Hilgrim) my best suggestion is to have them send you a copy of their infertility criteria/policy. I was actually able to find my insurance company's via google. There should be cut offs (ie SA results, AMH etc) that will allow you to bypass the "try three before you move on" rule. We only had to do 2 IUIs due to DH's SA numbers. Also, the one year of trying criteria is based on your RE's medical notes submitted. Since it has been so long for you, your RE may not have even put it in the notes. HTH! We are under our review for FET approval right now.....

Quickly tried to find for U.HC, and was only able to find a very general document .The document through my insurance is titled "Medical Review Criteria for Infertility" if that helps for what to ask for. I found that very often the issue is that they just need more information and instead of just asking for it before they make a decision they will just deny it. Does your RE's office have a financial coordinator? Mine has been my lifeline! Any other questions, just ask!

liz4paws · June 2013

MrsSJE2011:
MrsSJE2011:
Been down this road all too much! As much as a blessing insurance coverage is (ie we would not be able to pursue ART at all if not for living/working in a mandated state), it certainly adds another level of stress. Although I have a different insurance company (rhymes with Farvard Hilgrim) my best suggestion is to have them send you a copy of their infertility criteria/policy. I was actually able to find my insurance company's via google. There should be cut offs (ie SA results, AMH etc) that will allow you to bypass the "try three before you move on" rule. We only had to do 2 IUIs due to DH's SA numbers. Also, the one year of trying criteria is based on your RE's medical notes submitted. Since it has been so long for you, your RE may not have even put it in the notes. HTH! We are under our review for FET approval right now.....
Quickly tried to find for U.HC, and was only able to find a very general document .The document through my insurance is titled "Medical Review Criteria for Infertility" if that helps for what to ask for. I found that very often the issue is that they just need more information and instead of just asking for it before they make a decision they will just deny it. Does your RE's office have a financial coordinator? Mine has been my lifeline! Any other questions, just ask!

Thank you so much. I will look into this. Yes, my RE's office has a coordinator, but I've had nothing but problems with her. In fact, I had to complain about her to my RE officially yesterday.

liz4paws · June 2013

MrsSJE2011:
MrsSJE2011:
Been down this road all too much! As much as a blessing insurance coverage is (ie we would not be able to pursue ART at all if not for living/working in a mandated state), it certainly adds another level of stress. Although I have a different insurance company (rhymes with Farvard Hilgrim) my best suggestion is to have them send you a copy of their infertility criteria/policy. I was actually able to find my insurance company's via google. There should be cut offs (ie SA results, AMH etc) that will allow you to bypass the "try three before you move on" rule. We only had to do 2 IUIs due to DH's SA numbers. Also, the one year of trying criteria is based on your RE's medical notes submitted. Since it has been so long for you, your RE may not have even put it in the notes. HTH! We are under our review for FET approval right now.....
Quickly tried to find for U.HC, and was only able to find a very general document .The document through my insurance is titled "Medical Review Criteria for Infertility" if that helps for what to ask for. I found that very often the issue is that they just need more information and instead of just asking for it before they make a decision they will just deny it. Does your RE's office have a financial coordinator? Mine has been my lifeline! Any other questions, just ask!

Thank you so much. I will look into this. Yes, my RE's office has a coordinator, but I've had nothing but problems with her. In fact, I had to complain about her to my RE officially yesterday.

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