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Overview

Over the last several decades, cancer survival rates have tremendously increased, largely due to enhanced early detection and improved therapeutics. What was once considered a “death sentence,” now allows survivors to imagine a life after cancer with expectations beyond survival [1]. These medical achievements should be tempered by the resultant gonadotoxic effects. As such, survivorship issues are of increasing importance. Fertility loss is of particular concern for the approximately 135,000 pediatric, adolescent, and young adults (AYA) diagnosed each year [2]. Infertility caused by cancer treatment is iatrogenic, meaning any adverse condition induced by medical interventions including reactions from prescribed drugs or from medical and surgical procedures. Iatrogenic infertility is typically caused by cancer treatments such as chemotherapy, radiation, or surgical removal of reproductive organs. While the focus of this chapter will be specific to cancer patients, fertility may be compromised by treatments for other conditions such as autoimmune disorders.

While cancer screening, diagnosis and treatment are commonly covered under most insurance plans, fertility preservation (FP) is not, despite growing evidence of reproductive dysfunction resulting from treatments [3–5]. Further, many insurance companies will cover treatment for other iatrogenic conditions cause by cancer treatment [6], such as breast reconstruction after mastectomy for breast cancer. Patients at risk for iatrogenic infertility are different from patients treated for infertility. Infertility is defined as the inability to conceive after 12 months. Cancer patients may not have infertility at the time of diagnosis, but they need to undergo fertility preservation services prior to initiation of cancer treatments, which may impart risk of becoming infertile in the future. For example, a young woman with newly diagnosed lymphoma may choose to cryopreserve oocytes before starting treatment. Although she may have normal reproductive function at the time, her ability to have biological children in the future may be impaired. Therefore, she may choose to preserve oocytes to secure her fertility wishes. Even when traditional insurance has provisions for infertility treatments, cancer patients are often denied coverage because they do not meet the strict criteria of infertility, which limits coverage to those who have been trying to conceive for at least 6–12 months. This definition excludes most cancer patients attempting to access fertility preservation treatment.

While there is ongoing discussion and debate about insurance coverage for fertility preservation at a local and national level, the following sections outline strategies that may facilitate assess to fertility preservation services for patients.

Preauthorization for Oncofertility Consultation and Treatment

Most insurance companies have provisions covering consultations with specialists. An important component to ensure this coverage is the referral to an oncofertility specialist. It is critical for patients and office staff to understand the process to receive pre-authorization coverage for consultations with a reproductive endocrinologist. These patients benefit from understanding the full endocrine impact from their specific cancer treatment and all the potential associated side effects including menstrual irregularities, sub-fertility and infertility, sexual dysfunction, metabolic disturbances, cardiovascular and bone health. See Appendix 1 for a sample oncofertility referral form.

While there may be differences in specific procedures for pre-authorization across insurance companies, most will have guidelines about the process that are accessible via phone or online. Many insurance companies have specific pre-authorization forms that are available on their Web site that can be faxed to your office. Another important component to achieving insurance coverage is the use of appropriate diagnosis codes for the visits. The International Classification of Diseases (ICD) is the classification system used to code and classify disease states and mortality data and was designed to promote international comparability of these statistics [7]. Health care providers use the ICD system to code diagnoses associated with particular hospital and office visits, and are used by insurance companies to justify coverage for the visit.

For oncofertility patients, it is essential to use the cancer diagnosis as the primary diagnosis code for the consultation. In addition, there is a supplementary classification of factors, known as V codes, which influence the patient’s health status and contact with health services. In fact, special V codes for fertility preservation have been developed and are billable medical codes that can be used on reimbursement claims. These V codes should be used for preauthorization and all subsequent visits (Table 14.1). If a patient wishes to proceed with FP treatment, it will be helpful to submit a separate pre-authorization form for the specific FP procedure. Often, this is coupled with a Letter of Medical Necessity.

Table 14.1 Supplemental V codes for fertility preservation
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Communication About Medical Necessity for Fertility Preservation Procedures

Insurance companies often use medical necessity to review benefits coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for its members.

For example, one insurance company, Cigna Healthcare®, states that the medical necessity process is based on health care services that a Physician, exercising prudent clinical judgment, would provide to a patient, and that are:

  • In accordance with the generally accepted standards of medical practice;

  • Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury, or disease; and

  • Not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease [8].

Oncofertility specialists can submit a comprehensive letter that establishes medical necessity, which includes the following topics:

  • Patient name and date of birth

  • Insurance carrier name and patient identification number

  • Clinical diagnosis and ICD code

  • Cancer treatment plan

  • Side effects of the treatment plan associated with reproductive health

  • Proposed ICD-10 codes and associated V-codes that you are requesting coverage

  • Case for coverage (see below)

  • Physician signature

  • Your contact details

Case for Insurance Coverage for Oncofertility Services

There are a number of factors that can be included in the letter of medical necessity to support insurance coverage for patients. These include [9]:

  • Guidelines from professional organizations: The American Society of Clinical Oncology (ASCO) and American Society of Reproductive Medicine (ASRM) promote discussion of fertility impact of treatment at the time of diagnosis and have published guidelines discussing the incorporation of oncofertility in cancer care.

  • Iatrogenic Condition: Cancer patients often undergo gonadotoxic treatments that are medically necessary to overcome malignancy, but that may impart iatrogenic infertility. Cancer benefits typically include insurance coverage for the remedy of iatrogenic conditions. This includes procedures that are otherwise considered elective, such as surgical scar revision.

  • Right to Parity: This concept is related to non-maleficence meaning to “do no harm” and argues that insurance practice should mitigate iatrogenic effects caused by cancer treatment.

  • Benefit Already Exists: Some patients may have infertility coverage in their insurance plans. Although they may not meet the strict criteria for infertility, an argument can be made that they are at significant risk of permanent infertility as a consequence of cancer treatment. Fertility may be so impaired that assisted reproduction will be ineffectual in the future; therefore they will not be able to take advantage of this covered benefit.

  • Low Usage, Low Cost, and Positive Returns: The at-risk population is small and the proportion of insured members that will utilize the service is also small. Further, the cost per member per month is low with potential for significant positive cost offsets in the future. Patients who are unable to pursue FP prior to cancer therapy may become subfertile and utilize more assisted reproductive resources in the future.

  • Avoids Risk of Adverse Selection: The narrow window of time between cancer diagnosis and initiation of treatments discourages patients from switching insurance policies to take advantage of a FP benefit.

In addition to diagnostic codes, some insurance companies require a list of procedures associated with FP that a patient is seeking insurance coverage. The Current Procedural Terminology (CPT) is a universal coding system in which numbers are assigned to every medical service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. Insurance companies use these codes to determine which procedures are covered and the amount of reimbursement. Table 14.2 outlines CPT codes for standard fertility preservation treatments that are useful in writing letters of medical necessity (Table 14.2) [10].

Table 14.2 Standard ICD codes to use for fertility preservation procedures
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The following codes are typically excluded, but may be possible in other aspects of an insurance plan:

  • Assisted reproductive technologies for future conception

    • Intrauterine insemination (58321, 58322, 58323)

    • Thawing of cryopreserved embryos (89352)

    • Thawing of cryopreserved sperm (89354)

    • Preparation of embryo for transfer (89255)

    • Embryo transfer (58974, 58976)

  • Preimplantation genetic diagnosis (PGD) and other genetic testing (89290, 89291)

  • Assisted embryo hatching procedures (89253)

  • Donor egg, sperm or embryos (S4023, S4025, S4026)

A Letter of Medical Necessity is a critical aspect of insurance advocacy for patients and a letter template is provided in Appendix 2. Although it does not guarantee coverage for fertility preservation consultations or treatment, it may be the only opportunity a patient has to successfully appeal.

Appeal Process

The Affordable Care Act ensures a patient’s right to appeal health insurance decisions, including asking insurers to reconsider its decision to deny payment for a service or treatment. Plans created after March 23, 2010 specifically spell out how insurers must handle the appeal process. The law even permits its members to have an independent review organization decide whether to uphold or overturn the plan’s decision. The Letter of Medical Necessity and physician referral form are assets required for this process.

Insurers are required to let its members know:

  • The reason the claim was denied.

  • The insured’s right to file an internal appeal.

  • The insured’s right to request an external review if the internal appeal was unsuccessful.

  • The availability of a Consumer Assistance Program (when their state has one).

The law further protects your patients by requiring insurers:

  • To give their decision within 72 h after receiving a request for an appeal regarding the denial of a claim for urgent care. (If the appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time.)

  • 30 Days for denials of nonurgent care not yet received.

  • 60 Days for denials of services already received.

Many insurance companies facilitate the appeals process online for its members and is historically something your patient must work through independently with the support of your Letter of Medical Necessity, summary notes and physician referral. Patients can also submit a letter of appeal for fertility preservation on their own behalf (Appendix 3), in addition to letters of support from patient advocacy groups.

Insurance Reform: State Laws Related to Insurance Coverage for Infertility Treatment

Over the past 30 years, 15 states—Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia—have passed laws that require insurers to either cover or offer coverage for infertility diagnosis and treatment. While most these states require inclusion of coverage for in vitro fertilization (IVF), California, Louisiana, and New York have laws that specifically exclude coverage for IVF. These mandates, which are not specific to cancer treatments, are illustrated in Table 14.3 [11]. In contrast, states across the nation currently do not require insurance coverage for infertility treatments for people who may become infertile as a result of cancer or medical treatments.

Table 14.3 Mandated coverage for infertility treatments available in 15 states
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To date, three states have introduced legislation proposed to expand existing coverage of infertility caused by cancer treatments. However, none of these measures have become law. In 2011, California Assembly member Anthony Portantino was the first legislator to author a fertility preservation bill. California Assembly Bill 428 required health plans and policies to cover “medically necessary expenses for standard fertility preservation services when a necessary medical treatment may directly or indirectly cause iatrogenic infertility to an enrollee [12, 13]” The California Health Benefits Review Program analyzed the fiscal impact of this bill and estimated an increase premium of $0.03 per member per month. This bill was not approved by the state appropriations committee and will be reintroduced at a later time.

In 2012, two states attempted to pass legislation for fertility preservation. A bill introduced in New Jersey aimed to require insurers to cover medically necessary expenses for preventing infertility in women undergoing chemotherapy or radiation therapy for the treatment of cancer through oocyte cryopreservation. This differs from Hawaii House Bill 2105, which provides coverage for established preservation procedures to both men and women who are: (1) of reproductive age, and (2) diagnosed with a cancer or undergo cancer treatments that may adversely affect fertility. However, the bill identifies only two specific fertility preservation methods—sperm and embryo cryopreservation [14].

Finally, Senator Claire McCaskill (D-MO) introduced a provision in the National Defense Bill which would provide “additional coverage of fertility treatments for military members who may require such treatments due to chemotherapy, radiation or surgery in order to ensure military service members who face loss of fertility due to medical treatments have a chance to preserve their ability to have children.”

As the national conversation for expanded insurance coverage to include fertility preservation evolves, a number of advocacy groups are actively collaborating with key legislators to address this issue. For instance, the Livestrong Foundation and the Cancer Legal Resource Center joined together to develop a position statement outlining standards for health insurance coverage to address the fertility needs at the time of a cancer diagnosis. Key points include statements regarding insurance coverage for standard fertility preservation services for iatrogenic infertility should be dependent on a diagnosis of a medical condition requiring treatment that may cause infertility, not a diagnosis of infertility; and that all coverage language should be written so that when experimental fertility preservation treatments become standard practice as determined by appropriate professional societies, they become a covered benefit [15].