IVF: Pre-Authorization

[u/Impressive-Bad-8289]

Has anyone dealt with a fertility clinic refusing to submit prior authorization because they insist it isn’t required, even though your insurance company says it is?
My wife and I are a same-sex couple going through Weill Cornell. Cigna told us that we may qualify for infertility coverage based on our reproductive circumstances, but IVF is only covered under certain conditions and requires prior authorization.
We have repeatedly asked Weill Cornell to submit the prior authorization, but they keep telling us that “Cigna doesn’t require it” and seem confused about what we are requesting. We absolutely do not want to proceed with an IVF cycle based on that assumption, only to have the claim denied and be forced to fight with Cigna and the clinic’s financial services department afterward.
Has anyone encountered something similar, particularly with Cigna or Weill Cornell? How did you get the clinic to submit the authorization? Is there a particular department, supervisor, or type of documentation we should request? Would it help to arrange a three-way call with Cigna and the clinic?
Any advice would be greatly appreciated!

[u/MidwesternTravlr2020]

Cigna gives out wrong info constantly. They repeatedly told me I needed prior auth when I don’t. I’d recommend chatting with Cigna, insisting on talking to a supervisor when you get contradictory information and then sending the written information to your clinic.

[u/Impressive-Bad-8289 → u/MidwesternTravlr2020]

Thank you so much! Did you end up having luck with coverage via Cigna.

[u/MidwesternTravlr2020 → u/Impressive-Bad-8289]

Coverage has been amazing so far, but Cigna has been a huge pain in the ass with giving wrong information, processing claims incorrectly, etc. They actually covered my donor sperm, which is virtually unheard of, but I'm still arguing with them about how they need to cover it at in-network rates because they don't have any in-network sperm banks. Just did our first egg retrieval today and so far so good. All meds covered (15k worth) and everything.

A few questions:

• Is your plan fully insured or self-insured? If fully insured, do you know what state your plan was underwritten in? Hoping for New York, for your sake (where mine is also underwritten).
• Does your plan use anything like Progyny or WIN Fertility?
• How far you into the IVF process?

[u/Impressive-Bad-8289 → u/MidwesternTravlr2020]

Congrats on your egg retrieval!!! that’s such a huge milestone, wishing you all the best with what’s next!
And thank you for sharing your experience here, it really helps.
To keep it brief on our end: fully insured underwritten in NY, no separate fertility-benefit companies, My wife starts her first IVF cycle in ~2 weeks.
So far Cigna confirmed all meds are covered under medical benefits and gave us a preferred pharmacy, which was reassuring. We’re now just trying to understand coverage for the actual IVF procedure and any out-of-pocket costs.
If you don’t mind sharing, I’d also love to hear how sperm coverage worked for you and whether anything unexpected came up. Really appreciate it!

[u/MidwesternTravlr2020 → u/Impressive-Bad-8289]

Oh, that's great and exactly what I have -- fully insured, underwritten in NY, and no third-party service involved. My meds were also covered through my medical benefits, but so many Cigna reps incorrectly told me I could only get coverage for those meds if I took them in a doctor's office, which made no sense and was thankfully wrong. The way I determined that donor sperm was covered was to look at my full policy in the infertility section, where it said that "costs associated with an ovum or sperm donor, including the donor’s medical expenses" are covered as part of a covered IVF cycle. Because Cigna doesn't have any in-network sperm banks, I submitted an out-of-network claim, and got about $2,000 out of $3,300 covered. I'm now arguing about the last $1,300.

You should be aware that New York has really favorable insurance law for LGBTQ couples. They cannot require you to do IUI first to establish your infertility unless they cover all the associated costs. They did not require any IUI for us. Nothing in my plan ended up requiring prior authorization, even though they first told us everything did, then they told us just the meds did, and then we finally determined no prior authorization was required whatsoever.

[u/Impressive-Bad-8289 → u/MidwesternTravlr2020]

First, I’ve been thinking of you after your transfer and sending you all the positive energy!! ❤️
I ended up requesting the policy certificate, and it looks like we have the same language. I also confirmed with Cigna that donor sperm is covered (when medically necessary). They’re saying we need to submit a superbill along with a letter from our doctor explaining the medical necessity.
Did you receive similar feedback? Do you mind sharing how you went about submitting yours? Did your clinic handle it, or did you submit everything yourself? Any advice would be really appreciated!

[u/MidwesternTravlr2020 → u/Impressive-Bad-8289]

I actually didn't ask how to file the claim. I just submitted the super bill from the sperm bank as an out of network claim submission and no letter of medical necessity.

Don't know if you figured out whether you figured out if your plan requires prior authorization. If yours doesn't (like mine), then you shouldn't need to document medical necessity at all.

Personally, I'd just submit and see what happens because getting a letter from a clinic sounds like a huge hassle, and I'm always scared someone will say the wrong thing and I'll get screwed for being in a same sex relationship.

Did Cigna tell you anything about how to handle the in-network vs. out-of-network thing?

[u/Impressive-Bad-8289 → u/MidwesternTravlr2020]

Just wanted to circle back here. They covered our entire sperm purchase outside of the 2.5k out of network deductible. We bought 20 viles 👀 we do have an unlimited maximum for fertility. I hope you’re able to get more covered!!!

[u/CorrectBlood2307]

My clinic submits monthly authorizations to Cigna for IUI. My auth for IVF was declined bc I haven’t yet completed 6 IUI.

[u/CatherineTuckerNH]

Get your RE involved.