Helping women touched by cancer become mothers.
Accessing Insurance

Let’s cut to the chase. You most likely need to access your right to an appeal to gain coverage for fertility preservation. As unfair as that is, we are working so hard to make insurance coverage a permanent part of your cancer care. We are seeing success and want to help you!

Here’s why we need to do this together: Insurance companies are in the habit of reviewing a request for fertility preservation benefits through the lens of infertility, even though you aren’t infertile (yet). We recommend a PROVEN process (proven to work in certain states) to request they review your case through the lens of cancer, just like they do when considering breast reconstruction in the case of mastectomy. It’s not elective!

Insurance and the Law 

NOTE: 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. 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 hours 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 non-urgent care not yet received.
  • 60 days for denials of services already received.

After working with lawmakers and regulatory agencies, we recommend the following steps:

Three-Step-Process-e1456251870219

1. Your fertility specialist’s must submit an URGENT prior-authorization form with a Letter of Medical Necessity and Referral Form filled out by your oncologist NO MATTER WHAT TYPE OF INSURANCE OR COVERAGE YOU HAVE. They will list your cancer as the primary diagnosis and procreative management as the secondary.  They need to include the V-codes for fertility preservation procedures you are requesting.

Appeal Process

2. Patient’s file an expedited appeal through your carrier. Include the Letter of Medical Necessity and Statement of Urgent Need by your Oncologist. If you receive another denial, go to step 3

3. Each state must have a way to request an URGENT Independent Medical Review or URGENT External Medical Review. Follow these links to your state:

California

New York

Texas

Virginia

Please let us know if you were successful or need assistance ! info@fertileaction.org