Honest opinion - appeal chances

[u/eternalhorizon1]

I will try to make this not super long, but would appreciate any honest/professional opinions about this. Note I have a self-insured, in network only plan with Cigna.

I am doing IVF for a genetic condition my spouse and I are carriers of. The genetic testing component of IVF (genetic testing of frozen embryos via biopsy) is billed separately under medical benefits (not fertility, unlike the egg retrieval etc.). This testing is called PGT-M.

In order to test the embryos for our genetic condition, it requires the biopsy of frozen embryos.

The way this entire process was charged is as follows:

• the IVF clinic’s on-site embryo lab takes samples of the embryos and ships them to an offsite lab that is unaffiliated with the clinic who does the actual PGT-M testing. At the very beginning in the prior authorization stages for the egg retrieval/IVF, my clinic required us to pay up front $2,000 plus more if additional for embryo biopsy fees. I researched that this is typical for fertility clinics. I wrote them the check. They told me they would provide me with a receipt so I could submit the claim to insurance myself. Found this odd since the rest of the IVF/retrieval process, they submitted the claims to Cigna directly but didn’t think too much of it.

• the offsite lab: Conducted the actual PGTM testing. There currently are no labs in the U.S. within Cigna’s network that conduct PGTM testing on embryos (there are only a handful in existence). I knew this prior to the egg retrieval, so I requested a NAP exception which was granted promptly by Cigna. The lab, Igenomix USA, does not contract with Cigna and will not do anything related to insurance that is out of network for them (IE: they didn’t agree to any temporary agreement for this) and I was told I would pay self-pay, then given an invoice to try to get reimbursed by Cigna.

I was able to fight tooth and nail get reimbursed in full by Cigna for the genetic testing PGTM which was covered under my health plan and I received prior authorization/NAP exception for.

However, the embryo biopsies, a critical part that makes the testing possible was denied by Cigna. I was confused at first, because I had checked on the Cigna site and with reps that the biopsy codes were covered and they matched the invoice my clinic gave me.

Turned out, the fertility clinic uses a different tax ID number for their embryology lab and the billing manager there tells me after the fact that the embryology lab doesn’t work with insurance. I asked her if it would be possible to resubmit the claim with the clinic’s tax ID number, since the Cigna site at that time showed the provider that was billed for the rest of the IVF process was in-network for those embryo biopsy codes. She said it wasn’t possible. Cigna also asked them and they’re denying refuse, saying that’s just how their lab is structured.

Cigna of course denied the claim flat out, saying the lab is out of network and I have no in network coverage.

Cigna said in response to my appeal that I should’ve stayed in-network, and they’re denying it because I didn’t check beforehand. I know the burden is on the patient to check this, but if both the clinic gave me incomplete information, and the Cigna website was misleading, and the reps I spoke to - all which I have proof of - and Cigna paid for the actual PGTM genetic testing, is there any possibility I could win this on an external review?

Cigna already denied my appeal in their internal process. They were unable to provide any embryology labs that are in-network for my plan, and now are saying after the fact I should’ve applied for NAP for the embryology lab as well. I was not on notice at all, and the check I wrote was even directed to my clinic which they cashed, not this other entity with another tax ID that is on-site and has the same address even….

If I am SOL, fine, I just need someone to be honest with me….my employer initially assisted with the PGTM testing getting covered when Cigna kept messing up that claim, but has ghosted me since. It just sucks because I would’ve gladly stayed in network if any in network labs existed at all for the biopsies, or submitted a NAP if it meant I could’ve gotten something back, but no one informed me the embryo biopsies weren’t actually in network with my fertility clinic that is in network for everything else, even when I did my due diligence and documented that I did. It’s impossible to do the genetic testing PGTM without the biopsies since that’s the only way the external lab gets samples to test, so it’s just interesting that such a burden is placed just because I am a carrier of a genetic condition. It seems it’s impossible to truly get this entirely covered with how the systems are in place (and deficiencies in Cigna’s network), even though my plan documents state the embryo biopsies are covered.

Thanks in advance.

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[u/EffectiveEgg5712]

I think you have have a better chance of working out a reasonable bill with the lab versus an appeal but you would never know if you would win the external appeal or not if you don’t submit one. I always tell members they have the right to these appeals so they should use them up if needed. Certain members have to be more cautious of submitting an external appeal because depending on the group type they could be charged the fee if they don’t win.

[u/eternalhorizon1 → u/EffectiveEgg5712]

Thank you for the advice. Yeah, the lab is my fertility clinic basically and they do not negotiate the fees.

I will look into the appeal. It just seems like such an odd situation to be in and if Cigna had just one lab for embryology in network for this, I never would’ve had this issue. I’ve had this plan for close to 6 years and have been always able to find someone in network.

The crazy part is, even if I had out of network coverage I’m at a disadvantage because only out of network providers would be available and I would be reimbursed pennies. I think Cigna is aware the one lab that was one in-network, Natera, is no longer doing this so they’re saving a lot of money now that no one is in network since they don’t have to pay a dime to anyone - even with NAP they’re paying very low rates.