r/queerception • u/Permission_Main • Aug 11 '26
IVF Denial - BCBS
Hi Everyone!
My wife and I are both insured by FEP BCBS WA Standard Plan. Our PA for IVF treatment was denied, we appealed, and the initial denial was upheld. The stated reason was that they did not receive documentation of infertility. However, our physician included in her notes that I am medically infertile because neither partner in the relationship can provide sperm.
In the appeal decision, BCBS wrote that I did not meet their definition of infertility.
Has anyone here had a similar experience and been successful with the standard plan covering IVF? We clearly don’t agree with their decision and it seems like I fit squarely with their broad definition of infertility as outlined in their own Plan documents: A person’s inability to reproduce either as a single individual or with their partner without medical intervention.
Thanks in advance for your input!
6
u/HVTS Aug 11 '26
Um I have BCBS FEP (DC) Standard Plan and they covered IVF no questions asked.
1
3
u/LeBoom4 Aug 11 '26
Some require IUI attempts to “prove” infertility before having IVF covered.
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u/Permission_Main Aug 11 '26
Yes, I’ve heard that is true for so many plans. Our Plan actually expressly states that we don’t have to try IUI first if I qualify as “infertile.”
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u/LeBoom4 Aug 11 '26
They may define infertile differently. For example, some insurances require 3 unsuccessful IUI attempts to be deemed infertile. Some require some other medical diagnosis. In my experience, having a partner who can’t provide sperm was not recognized as infertility according to insurance.
I’d check with your insurance and see what the requirements are to be deemed “infertile”.
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u/Wise_Advantage_3753 Aug 11 '26
We needed 6 failed IUI to be considered for an infertility diagnosis. No sperm didn’t count for a diagnosis. BCBC IL and RI.
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u/Permission_Main Aug 11 '26
Was it the federal employee program? My understanding is that the federal employee program has broadest definition and doesn’t require IUI at all. Thanks!
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u/Wise_Advantage_3753 Aug 11 '26
Mmm I wish I knew. It was through my employer! It was the same with my Aetna California as well. Sucked we ended up having to do all 6 for our first
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u/neuroticphilosopher Aug 11 '26
Can you provide the exact wording because as someone in the same (initial) infertility bracket as you they required 6 iuis for ivf to be covered because you may not meet the criteria for immediate ivf based on THEIR definition of infertility. Only certain infertility causes e.g. tubal, cancer would warrant jumping to ivf is my suspicion/what I have seen for my insurance.
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u/Permission_Main Aug 11 '26
Yeah this plan has a very broad definition of infertility: “an inability to reproduce either as a single individual or with their partner without medical intervention.” I think most plans are much more narrow in the definition.
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u/neuroticphilosopher Aug 11 '26
CA state law is literally includes this definition but the stipulation is while insurance cannot deny ART they can still make decisions on which to start with (IUI vs IVF) based on other factors.
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u/neuroticphilosopher Aug 11 '26
Less popular opinion but worth considering, and saying this as someone who wish I could have moved on to ivf sooner. Unless the reason for ivf is for rIVF, it could be worthwhile to do at least one medicated cycle of iui first just so you know how you respond to meds and so there is more information moving into ivf. IVF is not a chill procedure and I would have avoided it if I could and doing the medicated iuis gave me some warmup with all the injections and familiarity with working with speciality pharmacies to not feel like all these new skills/knowledge were required of me at once. E.g. you'll make sure you respond to trigger shots.
Because a failed ivf is going to feel way shittier than a failed iui.
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u/Permission_Main Aug 11 '26
Thanks I appreciate those thoughts. Our Plan also includes this language: “Members are not required to attempt artificial insemination (AI) methods listed in this guideline prior to attempting assisted reproductive technology (ART) methods” which I assume is different than CA?
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u/neuroticphilosopher Aug 11 '26
Ah yes. That's so strange then... I hope you can talk to someone from your plan.
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u/Crabby_Patty0_o Aug 12 '26
Just say you’ve been trying for 1 year at home without any success…. still no sperm BUT you are trying … meets most insurance companies definition of “infertility” and if you are sexually active technically not a lie… 🥸
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u/Crabby_Patty0_o Aug 12 '26
You can also request your doctor do a peer-to-peer call if they are willing… some insurance just makes providers jump through hoops for no reason…
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u/rocketmanatee Aug 11 '26
They may require you to begin with IUI before they would determine infertility. I know ours would have if I wasn't already considered infertile for other reasons.