Does GHI Require Pre-Authorization for FET/PGD?

Hi,

I have a city GHI plan and know that they require pre-authorization for IVF. However, does anyone know if they require pre-authorization for FET? What about PGD? I took a look at the insurance work-up that my clinic did and was shocked to see that GHI covered PGD and was wondering if anyone knew if pre-authorization was required for this? I'm thinking ahead if my current IVF does not work out. Thanks.

Re: Does GHI Require Pre-Authorization for FET/PGD?

GHI did not cover anything for me except 2 rounds of IUI. They wanted me to do 12 rounds before they would approve one round of IVF.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Yes. I am pretty sure we have the same plan. I needed to get pre-auth for everything, icluding my FET. They cover 3 Fresh and and 3 frozen, but each one need to get pre-authorized.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Can I ask - do either of you have unexplained infertility or a diagnosis? I was told that with unexplained they would not cover IVF until we did 12 rounds of IUI.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Thanks Maybemommy...that is what I thought.

Anne...you can apply for a waiver. I am 43 and GHI had a requirement of 3 or 4 IUI's at my age before approving IVF...down from 6 under the city plan. THAT is just ridiculous at my age. In any event, at the time I first applied for a waiver I had already had one unsuccessful IUI. My Dr. thought that they would approve a waiver based upon my age and they appealed the denial of coverage for IVF for me. GHI still refused to cover IVF but now said that they they would only reuqire that I do 1 more IUI...so...my requirement was 2. When the second IUI one failed we had to apply for coverage again and this time they approved it. So..yes...I am unexplained...except for age I guess.
My Dr. had to say that IVF was a medical necessity for me...which it was. It's a crap shoot...my Dr. had a patient one year younger than I for whom GHI waived the requirement and she was not even in as bad a situation as I was...I guess much depends upon whomn is reviewing the claim that day.

I have read of GHI waiving the IUI requirement for several others. At the very least, have your Dr. make the case for why it does not make sense in your situation to do IUI. Do you have any male infertility issues...even if your partner has a good sperm count...perhaps there is a motility, aggregation, etc issue. Perhaps there is evidence in your case that IVF is needed as you keep having chemicals and such..I don't know...just thinking off of the top of my head...but it can be done.

It's worth a shot to appeal a denial for IVF and get the IUI # requirement down. GL!!


Anyone get GHI to approve PGD?

Re: Does GHI Require Pre-Authorization for FET/PGD?

Thank you for the help! We are unexplained and just paid out of pocket for IVF, then I hyperstimulated so had to postpone transfer and wait for an FET which resulted in a chemical and recently did another FET last week (hoping for good results). I cannot even begin to tell you how much we have spent out of pocket this year. Of course, no male factor, and no female factor to be found, although my Dr. is pretty sure it is a combo of many things. UGH!! Wishing you guys the best of luck!!! I don't even have medication coverage!!

Re: Does GHI Require Pre-Authorization for FET/PGD?

I am 34, dx 'unexplained' and they approved both my fresh and frozen.

Re: Does GHI Require Pre-Authorization for FET/PGD?

How many IUI's did you do? I think my doc didn't mind me paying out of pocket and prob didn't even try to get it approved. He said there was not way. UGH!!

Re: Does GHI Require Pre-Authorization for FET/PGD?

Message edited 11/22/2010 6:02:41 PM.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Re: Does GHI Require Pre-Authorization for FET/PGD?

Re: Does GHI Require Pre-Authorization for FET/PGD?

Message edited 11/22/2010 10:57:00 PM.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Re: Does GHI Require Pre-Authorization for FET/PGD?

i am not a city teacher, but work for the city. I have GHI. We did PGD/IVF and had I think 80% coverage. We still had to pay out of pocket a little bit.

DH had low sperm count so we were able to get coverage that way. In addition I had a late loss and am a carrier to a genetic disorder, so I think all taken together, we were able to get coverage.

We did require pre-auth. We plan on going through the process again for our second in about 8 months. Hopefully we will get coverage again.

Re: Does GHI Require Pre-Authorization for FET/PGD?

I wanted to say, everyone should call their own insurance and require IN WRITING what they have covered for IF. Insurance companies can be tricky little %uckers, GET EVERYTHING IN WRITING !!!!


Many insurances have different plans, riders, etc etc so its impossible to gage what someone has /hasn't.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Re: Does GHI Require Pre-Authorization for FET/PGD?

Hi ladies i work for GHI and because of my diagnosis of endo i have looked up this info many times!
First you MUST call and find out what your policy has...city workers including teachers have one of the better policies.
sorry this is long but it is just part of the info straight from the Medical Policy:

Criteria

I. Precertification Requirements3 (See Appendix A)
It is the member’s responsibility to obtain prior approval.
2 In accordance with New York Consolidated Laws, Insurance, Section 3221 (k) (6), Section 4303(s).
3 Fertilization rates are considered poor if IVF cycles result in <50% fertilization
Assisted Reproductive Technologies (ART)
Last review: October 30, 2009
Page 4 of 13

1. Twelve months of frequent unprotected heterosexual intercourse or six months if the female partner is >age 35 years.
2. In women < age 35, including single female patients and same sex couples, the member must have undergone a total of 12 AI attempts; at least 6 of these with ovarian hyperstimulation.
In women > age 35, including single female patients and same sex couples, the member must have undergone a total of 6 AI attempts supervised by MD; at least 3 of these cycles with ovarian hyperstimulation.
In men with azoospermia or severe deficits in semen quality or quantity, and the couple accepts donor insemination, the number of AI attempts depends on the woman’s age.
3. FSH should be <12 on day 3 of the menstrual cycle for < age 42, and <15 for age > 42. 4
FSH test result valid for 12 months in women <35 years of age; result valid for 6 months in women >35 years. Clomiphene challenge test or other ovarian reserve test should be done every 12 months in women >40 years.
4. Estradiol value should be less than 100. An elevated estradiol with a low FSH is still consistent with decreased ovarian reserve.
5. LH must be within normal limits, as defined by the reference values of the laboratory processing the sample.
6. Reversal of elective tubal ligation or vasectomy. If an elective tubal ligation or vasectomy is reversed and the member is unable to conceive after meeting the clinical definition of infertility, then the member may be ART-eligible; however, the reversal of the tubal ligation or vasectomy is not a covered benefit.
7. ART is indicated (see section II)
II. ART Indications
Members who do not achieve conception through less invasive treatments (i.e., medical, hormonal therapy or surgical) may be treated with an ART procedure when either of the following criteria is met:

1. Failure of artificial insemination with gonadotropin (FSH) or clomiphene citrate ovarian hyperstimulation as noted above.
OR

2. Couples for whom natural or artificial insemination would not be expected to be effective including:

A. Men with azoospermia or severe deficits in semen quality or quantity, and the couple declines donor insemination.

B. Women with tubal factor infertility:

?? Bilateral tubal disease (e.g., tubal obstruction, absence or hydrosalpinges).

?? Endometriosis stage 3 or 4.

?? Failure to conceive post pelvic surgery with restoration of normal pelvic anatomy after;

i. Attempts to conceive for 6 months if < age 35.
ii. Attempts to conceive for 3 months if = age 35.
?? Infertility resulting from ectopic pregnancy.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Also, you can request a waiver...you do not have to go thru the 12 IUIs before IVF is covered. That is just the basic policy criteria.

please feel free to FM me with any other questions.

Re: Does GHI Require Pre-Authorization for FET/PGD?

Re: Does GHI Require Pre-Authorization for FET/PGD?

Hi,

I have a question for you-- what lab did you use? GHI told me they don't have any labs in network that perform PGD. Did you use out of network benefits? We used Genesis Genetics and had to fight with GHI for a year and go to OPM to get reimbursed because we didn't have out of network benefits. They ended up giving us less than half of what the lab charged us and claimed that was their basic allowance charge. I wish we got 80%!

Thanks!