My Insurance Denied Trisomy Screening

MrsT4 · March 2014

Well, unfortunately, I just found out that my insurance company denied the non-invasive prenatal trisomy screening test (Harmony/Panorama). The main reason it was denied was because they felt it was not medically necessary, given the fact that we used an egg donor that was under 35 years old.

I dug a little further and found out that Harmony/Panorama doesn’t even work with donor eggs and that I could try to see if MaterniT21 would be covered, as I was told that this test would work with donor eggs. Well, the frustrating thing is that the lab won’t run MaterniT21 because I’m considered low risk because they go by the age of the donor eggs. It doesn’t matter that I’m AMA (in my early 40’s) or that my husband is in his middle 40’s.

It’s just frustrating because I was looking forward to having some peace of mind by having this test. And even though I’m supposedly “low risk”, it is my understanding that Trisomies are random occurrences and can happen to women of any age…so frustrated!

I’m guessing there aren’t any other donor egg mommas that have had this test performed? I’m also perplexed because I don’t know anyone that would use an egg donor who is 35 or older (unless maybe it was a known donor?)

No real point to this post, except to vent a little and to let other donor egg recipients know about this, just in case you were not already aware.

liz4paws · March 2014

I'm really sorry. I had a lot of questions about Mat21 and I called their lab a couple of times. I am under 35 and my donor mother was under 35, but my OB felt that because we didn't know the heritage of one of our donor embryos, I was high enough risk to have the test run. Truly, it wasn't probably a good reason but OB gave it. I called Mat21 customer service and they said they trust the OB's judgement and if the OB says you are high risk, that's all they need. They won't question your OB.

Does your OB feel you need this test? If so, I'd go with Mat21.

Also, a VERY important thing about Mat 21 - they have a max out of pocket price they offer to everyone and it's just a couple hundred dollars. They will bill your insurance, and if it is denied (or covered even) the most they will charge is 200 something dollars. Mine worked out exactly as promised. Insurance paid some, but then left me with 800 something dollar bill. I called Mat21 people and they quickly adjusted it to 200 whatever. Easy as that. You may want to give them a call and see if your OB would push forward on the test for you based on your age? And yes, to my knowledge Mat21 is the only one that works with donor eggs/embryo.

So sorry you're running into problems.

[Deleted User] · March 2014

The user and all related content has been deleted.

MrsT4 · March 2014

Thank you @Liz4paws and @JimBobCooter for your input. It is very much appreciated

Liz - I guess I live in the wrong state (NY) because supposedly I have to meet at least one of the four criteria for me to be considered "high risk" and to be eligible for the test. I don't think my OB will fight for it, because whatever she told my insurance company wasn't good enough for them to approve the Harmony test either...ugh, it's just so frustrating!! Also, thanks for the info on the pricing. I was actually in the process of trying to verify the price and that is when I found out that the "the lab will reject your sample" if I did not meet one of their high risk criteria.

JimBob - I hope you have better luck when the times comes. I'm also very sorry for your losses! ((hugs))

I also called Verify to see if they had any restrictions on the test, but they said I would need my OB to call and discuss it. But, when I probed further, it also sounded like the NY requirement would apply as well....and I would need to be classified as "high risk". The only thing the woman at Verify said is that she didn't think they would reject my sample...if I wanted to pay for it OOP I could....but she would not quote a price either. ~X(

liz4paws · March 2014

I'm not sure if it's state by state, but I also had to meet one of the four criteria you mentioned. Its just a matter of the OB check-marking one of them when he submits the sample. I don't remember what the four were, but I'm pretty sure they were pretty general. Your OB won't need to fight. If he believes you even remotely fit into one enough for him to checkmark it, you're golden. They wont question it if he checkmarks it. This is for sequenom, NOT for your insurance. But again, if your insurance denies, sequenom will only have you pay 200ish. The key is if your OB thinks you need it and can checkmark the right box on the form. I really hope that helps! I did a ton of homework on it

ETA: Insurance is WAY stingier with approving these than sequenom will be. So I wouldn't use the fact that your insurance wouldn't approve harmony to be enough to discourage you from talking to your OB about the minimal form needed for Mat21. Good luck!

chicagobride_07 · March 2014

I had the verifi test at 12 weeks. I chose to pay OOP. It was around $400. I was worried about insurance as I could not find out if verifi was considered in network or not. After talking to verifi billing- they are great- they warned me that if I used insurance, and had a high deductible, they'd be required by law to bill me for it. They mentioned many times the cash price is much less. So I didn't even bother submitting to insurance. They will absolutely run the test if your MD orders it. I loved having the piece of mind and knowing the sex so early on. GL!

cc+mm · March 2014

We ended up doing Maternit21 after talking to my ob. He said sequenom told him they would never charge a patient more than $200. He checked the box for AMA (I'm 40, but donor was 27) and sequenom did the test. As of now my insurance is denying, but I haven't been billed yet. My ob said if they charged me more than $200, he would call them personally.

2MamazInSeattle · March 2014

First, I'm so sorry this is being a pain! Second, I never heard only Matt21 works with donor eggs?! I have Verifi with our loss baby, and Harmony this time ordered by my MFMs, which I doubt they'd order if they didn't work.

I've heard as well that Mat21 will do the $200 out of pocket max. Have you considered asking your RE to sign off?

And last, our egg donor was older (31) but very proven, had several healthy babies...but as you know, I tested positive for Trisomy X, and while not the end of the world, it is good to know about it. My doc submitted it due to my age and just didn't mention it was a donor egg...

lincoln79 · March 2014

First, I am sorry that this has been such a pain. Second, it looks like you have some great info from pp.

Silly (possibly off topic) question here - I am assuming that in the case of a GC, that Mat21 would also be the only one that would work since she is (for all intents and purposes) carrying a donor embryo?

BeckyP005 · March 2014

I'm sorry

Hoping somehow you can make this work so it's covered.

MrsT4 · March 2014

liz4paws said:

I'm not sure if it's state by state, but I also had to meet one of the four criteria you mentioned. Its just a matter of the OB check-marking one of them when he submits the sample. I don't remember what the four were, but I'm pretty sure they were pretty general. Your OB won't need to fight. If he believes you even remotely fit into one enough for him to checkmark it, you're golden. They wont question it if he checkmarks it. This is for sequenom, NOT for your insurance.

Liz - according to my OB nurse, she told me that they (the OB's office) used to call and order it for patients all the time. However, since January the laws have changed, and she said I would have to call seque.nom directly, which is what I did. I called and spoke to someone in billing and she's the one who confirmed that they go by the age of the egg donor - not me. From what I recall, aside from myself being AMA, I don't think I would qualify for any of the other criteria. The whole thing is so frustrating and I have a strong feeling that my OB would not lie on the paperwork in order for me to have the test. That is why I tried calling Verify to see if their policy was the same. I do appreciate the additional info!

MrsT4 · March 2014

@chicagobride_07 - thanks for your input on the Verify test!! $400 isn't chump change, but it's certainly seems better than forking out $1-$2k....especially since I'm out of work at the moment. I'll need to call back the OB nurse and see if they can order the Verify test for me....not sure if the availability of these tests varies by state or not?

@cc+mm - thanks for sharing your experience with Mat21. Like I said, I'm pretty positive my OB won't identify me as AMA, since she knows we used donor eggs...which means Mat21 won't even accept my blood sample! Ugh!! Plus I would be worried that they would try to charge me the full amount of the test and I can't have that expense hanging over my head right now. Maybe if I was working, I would consider it.

@2MamazinSeattle - thanks for your input/experience as well! Yes, it does seem strange that I was told that Harmony doesn't work with donor eggs, yet you had it done?!?! %-( They have me so confused, I don't know what to think!! The unfortunate thing is that my insurance already denied the claim for Harmony and I don't know if they even offer a discounted cash price, because I certainly can't afford several thousand right now...ugh! Like I mentioned, I was told that it was up to me to arrange Mat 21 with seque.nom, the OB office doesn't deal with them directly anymore. Again, I don't know if this varies by state or not?

@lincoln79 - thanks for the kind words. I'm fairly certain you will be OK using a GC, as long as you are over 35 years old and you used your own eggs. My understanding is that it would not apply for people using sperm donors only, as they go by the age of the eggs. Honestly, I wish I had never disclosed the fact I was using DE's. Apparently, I didn't have to tell the OB this (according to my RE it was my decision), but now that I did I don't think she would falsify paperwork to say otherwise.

@BeckyP005 - thanks for your support! I'm honestly just so frustrated right now, I'm not sure what next steps I will take. My 12 week scan can't come quick enough!

liz4paws · March 2014

MrsT4 said:

liz4paws said:

I'm not sure if it's state by state, but I also had to meet one of the four criteria you mentioned. Its just a matter of the OB check-marking one of them when he submits the sample. I don't remember what the four were, but I'm pretty sure they were pretty general. Your OB won't need to fight. If he believes you even remotely fit into one enough for him to checkmark it, you're golden. They wont question it if he checkmarks it. This is for sequenom, NOT for your insurance.

Liz - according to my OB nurse, she told me that they (the OB's office) used to call and order it for patients all the time. However, since January the laws have changed, and she said I would have to call seque.nom directly, which is what I did. I called and spoke to someone in billing and she's the one who confirmed that they go by the age of the egg donor - not me. From what I recall, aside from myself being AMA, I don't think I would qualify for any of the other criteria. The whole thing is so frustrating and I have a strong feeling that my OB would not lie on the paperwork in order for me to have the test. That is why I tried calling Verify to see if their policy was the same. I do appreciate the additional info!

I'm definitely not thinking your OB should lie, but even as PP said, your AMA would be a checkmark on the form they need. Maybe it varies state to state like you mentioned and they have to call sequenom directly.

I am just super duper bummed that this isn't working out for you. I wish I could help somehow more. Big hugs. SO FRUSTRATING.

MrsT4 · March 2014

Thanks @Liz4paws!!! I really appreciate your support!

Like I said, I wish I had never disclosed I was using DE's, because then it would not be an issue.

One thing I forgot to mention, when I expressed my frustration to the OB nurse, she said she had a contact at seque.nom and she was going to try calling/emailing for me. I still think it's a longshot, though.

Want a personalized experience?

My Insurance Denied Trisomy Screening

Re: My Insurance Denied Trisomy Screening

Choose Another Board

Search Boards