Letter to the insurance company...

Here's the letter that I wrote to the insurance company. Pretty damn awesome huh?

Dear Review Committee,

I am writing to appeal as part of the formal review process for denial of in vitro fertilization coverage. In September 2006 Dr. Robert Kiltz’s office (CNY Fertility) appealed the initial denial of in vitro fertilization coverage based on the medical evidence that I had Polycystic Ovarian Syndrome and at that time had undergone 3 in vitro fertilizations, 5 intrauterine inseminations (IUI), and 1 intracervical insemination (ICI).

Following the appeal made by Dr. Kiltz, I was sent a letter October 6th, 2006 from the medical review board (Dr. Rosenberg) stating “If you are infertile you will be required to do 3 FSH/DS/IUI to be eligible for in vitro fertilization.” (See attached review letter.) Starting in November 2006 I underwent the three intrauterine inseminations required to meet the guideline set forth in the review letter by Dr. Rosenberg. (See attached cycle sheets.)

I was initially diagnosed with Polycystic Ovarian Syndrome by Dr. Jose Torrado (Cayuga Women’s Health) during my initial consult in October, 2002. I then did two IUIs with his office before transferring over to my current doctor – Dr. Kiltz.

Dr. Kiltz’s assessment concurred with Dr. Torrado’s, upon initial consult, and the diagnosis of Polycystic Ovarian Syndrome and Ovarian Dysfunction were given. (see doctor’s notes from Kiltz and Torrado)

I am currently on Glumetza 2000mg to treat the PCOS. I have been on Glucophage in the past and had intolerable side effects. The medications are supposed to help with egg quality and decrease the chance of miscarriage.

I have had the following treatments:

Treated with Cayuga Women’s Health – Dr. Torrado
11/19/02 – IUI w/Clomid, HCG
12/19/02 – IUI w/Clomid, HCG

Treated with CNY Fertility – Dr. Kiltz
1/19/03 – ICI w/Clomid and under supervision and direction
2/15/03 – IUI w/Clomid, HCG
3/12/03 – Did not ovulate this month and cycle was cancelled
4/7/03 – IUI w/Clomid, HCG, and Glucophage
5/2/03 – IUI w/Clomid, HCG and Glucophage
9/6/03 – IVF using donor embryos
12/22/03 – IVF

Treated with SIRM – Dr. Sher
8/18/06 – IVF using donor embryos

Treated with CNY Fertility – Dr. Kiltz
11/1/06 – IUI w/Gonal-F, Lupron, HCG
11/30/06 – IUI w/Gonal-F, Repronex, Lupron, HCG - resulted in miscarriage.
2/21/07 – IUI w/Gonal-F, Repronex, Lupron, Glumetza, HCG

Throughout all of the procedures and attempts of trying to get pregnant --- I have only achieved pregnancy once. That ended in a devastating miscarriage December, 28th, 2006.

The Center for Applied Reproductive Science states:

“First trimester pregnancy loss is increased in PCOS. The major cause of this is probably poor egg quality and problems that were present at the time of fertilization.”

When Dr. Kiltz appealed the decision from Blue Cross Blue Shield in September 2006, the consequent medical review letter dated October 6, 2006 clearly noted that once I completed three rounds of injectible IUI that I would be eligible for In Vitro Fertilization.

In addition, Dr. Rosenberg stated that “If the same donor’s sperm was used successfully with the donor eggs in 9/2003, it suggests that the problem is with your oocytes.” The sperm donor has proven fertility in over 15 different cases using many different women and both donor and non-donor ova.

Therefore, the only clear resolution that can be seen as to the reason for my infertility is “that the problem is with my oocytes” as noted in Dr. Rosenberg’s review.

By doing IVF that would allow the Embryologist and Reproductive Endocrinologist to choose the healthiest appearing eggs and allow for fertilization of sperm directly.

The American Society for Reproductive Medicine states:

“IVF is increasingly being used for treatment of PCOS. Perhaps the largest benefit, a desire shared by both clinician and patient, is to evaluate the capacity of the oocyte to be fertilized.”

It’s obvious that I am classified as infertile due to not only having issues with getting pregnant but also maintaining a pregnancy. I am currently being treated for PCOS and I do not ovulate nor do I start my period without assistance from medication.

The most recent injectible IUI I had over 14 mature follicles, an estrogen level of over 4,000 and risk of high-order multiples. Due to the ovarian hyperstimulation, I was advised to go to the Emergency Room for evaluation and treatment. I went through with the high-risk, FSH/DS intrauterine insemination because it was a requirement by Dr. Rosenberg in order for me to be eligible for IVF in the future

The American Society for Reproductive Medicine states that:

“An additional advantage (of IVF) is that a more aggressive approach can be taken toward ovarian stimulation. With PCOS, hyperstimulation is somewhat less of an issue because the preovulatory size follicles are aspirated and a limited number of embryos are replaced. Not only does this decrease the chance of multiple pregnancies, it reduces the risk of more pronounced cystic change.”

It’s clearly in my best interest to provide coverage for in vitro fertilization through my insurance plan. I have met all of the requirements of the prior letter sent by Dr. Rosenberg. I have also been diagnosed with Polycystic Ovarian Syndrome and Ovarian Dysfunction which are the most common causes of infertility.

I ask that the decision “to do 3 FSH/DS/IUI to be eligible for in vitro fertilization” noted in the October 6, 2006 letter be upheld and that coverage be granted in a timely matter. I am due to start Lupron March 29th and so I will need an immediate answer.

Please contact myself or Dr. Kiltz if you have any further questions.

I await your positive response so that I can achieve my dreams of becoming a mother.

Your paying customer,