IVF and Fertility Treatment Insurance Claim Denied: How to Appeal

IVF and Fertility Treatment Insurance Claim Denied: How to Appeal

Fertility treatment is one of the most emotionally and financially demanding healthcare journeys — and insurance denials for IVF (in vitro fertilisation), IUI (intrauterine insemination), egg freezing, and other assisted reproductive technologies (ART) are devastatingly common. But in many cases, these denials are wrong, challengeable, or superseded by state or national laws that mandate fertility coverage.

This guide covers how to appeal a fertility treatment insurance denial across multiple countries.

Why Fertility Treatment Claims Are Denied

"Infertility is not a medical condition" arguments: Many insurers classify infertility as a lifestyle or elective choice rather than a medical condition — despite the World Health Organisation (WHO) classifying infertility as a disease of the reproductive system. This classification is legally and clinically challenged in many jurisdictions.

Plan exclusions: Many insurance plans explicitly exclude fertility treatment, ART, and related medications. However, the enforceability of these exclusions depends on your jurisdiction and plan type.

"Experimental" classifications: Some insurers classify certain ART procedures (e.g., egg freezing for medical reasons — "oncofertility") as experimental, particularly for younger patients or for non-traditional family structures.

Prior authorisation not obtained: Many plans that do cover fertility treatment require prior authorisation. Failure to obtain it can trigger a denial even for covered services.

Diagnosis code issues: If the billing code on your claim doesn't correctly reflect infertility as a medical diagnosis (e.g., using the wrong ICD-10 code), the claim may be administratively denied.

Lifetime maximums: Fertility coverage (where it exists) often has lifetime dollar or cycle limits. Claims beyond these limits are denied.

In the United States: State Fertility Insurance Mandates

The most important thing to know: The United States has no federal fertility coverage mandate, but 19+ states have enacted fertility insurance mandate laws that require some or all health insurers to cover infertility diagnosis and treatment. If you live in one of these states, your insurer may be legally required to cover IVF:

States with IVF coverage mandates include:

• Arkansas, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Hampshire, New Jersey, New York, Ohio, Rhode Island, Texas, Utah, West Virginia and others

How to use state mandates:

1. Identify whether your state has a fertility mandate
2. Determine whether your plan type is covered by the mandate (most state mandates apply to fully insured plans — self-insured ERISA plans are exempt from state mandates, a significant limitation)
3. If your fully-insured plan in a mandate state denies fertility coverage, cite the state mandate in your appeal
4. File a complaint with your state's Department of Insurance

ERISA exception: Employer self-insured plans (common at large companies) are exempt from state insurance mandates. Check your Summary Plan Description to determine if your plan is self-insured.

New York's Fertility Mandate (one of the strongest): New York's 2019 Insurance Law requires coverage for up to 3 IVF cycles, IUI cycles, and fertility preservation for people facing certain medical treatments that may damage fertility.

Appealing a US Fertility Denial

Step 1: Determine if Your State Has a Mandate

Research your state's fertility mandate law. The National Infertility Association (RESOLVE) at resolve.org maintains a current state mandate database.

Step 2: Get Medical Documentation of Infertility Diagnosis

Your appeal must establish infertility as a medical condition:

• Letter from your reproductive endocrinologist (RE) diagnosing infertility and explaining the medical basis
• Evidence of a defined cause of infertility (e.g., endometriosis, PCOS, premature ovarian insufficiency, male factor infertility, blocked tubes)
• Documentation that less invasive treatments (IUI, medication) have been tried and failed (if applicable to your plan's step therapy requirements)

Step 3: Request Your Plan's Fertility Coverage Criteria

Ask your insurer to provide the specific clinical criteria they use to determine whether fertility treatment is covered. Review whether your clinical situation meets their criteria.

Step 4: Submit Your Appeal

Your appeal letter should:

• Cite your state's fertility mandate (if applicable)
• Include your RE's letter diagnosing infertility and recommending the specific ART procedure
• Reference WHO's classification of infertility as a disease
• Address any specific denial grounds (medical necessity, experimental, cycle limits)
• Request a medical reviewer at the same specialty level (reproductive endocrinologist, not a general practitioner) for appeals involving clinical judgment

Step 5: Request External Review

After exhausting internal appeals, request external review. External review processes in mandate states often have specialists in reproductive medicine on review panels.

Step 6: File a State Insurance Complaint

File a complaint with your state's Department of Insurance, particularly if your state has a fertility mandate and your insurer is ignoring it.

In the United Kingdom

The NHS provides IVF treatment in some circumstances (up to 3 cycles for eligible women under 40 in England), but coverage varies significantly by local NHS area. Private health insurance rarely covers IVF.

If you have private medical insurance that you believe should cover fertility treatment:

• Review your policy wording carefully — most standard PMI policies exclude fertility treatment
• If your infertility is caused by a medical condition that the policy does cover (e.g., endometriosis, damage from cancer treatment), argue that treating the underlying condition includes treating its fertility consequences
• File a complaint with the Financial Ombudsman Service (FOS) if the insurer's denial of a potentially covered condition seems incorrect

In Australia

Medicare covers some fertility testing and some ART-related procedures through Medicare Benefits Schedule (MBS) items. Private health insurance does not typically cover IVF cycles, but covers hospital costs for ART procedures conducted in a hospital setting.

If private health insurance is involved in a fertility denial:

• Review your policy's obstetric/gynaecological clinical category
• Escalate through PHIO (Private Health Insurance Ombudsman) if the denial appears incorrect
• Contact AFCA for broader disputes

In Singapore

Singapore's MediShield Life and most Integrated Shield Plans do not cover assisted conception procedures. However:

• Treatment of underlying conditions causing infertility (endometriosis, ovarian cysts) may be covered as medical treatment
• Some private health insurance plans offer elective fertility treatment as an optional rider
• If a fertility claim involves covered surgical treatment (e.g., laparoscopy for endometriosis), escalate to FIDREC if the claim is incorrectly denied

General Tips for Fertility Denial Appeals

RESOLVE (US) and Fertility Network UK: These patient advocacy organisations have resources, helplines, and legal information about fertility coverage rights. Use them.

Medical necessity framing: Always frame fertility treatment as medically necessary treatment for a diagnosed medical condition — not as a "lifestyle choice" or "elective procedure."

Oncofertility: If you need fertility preservation because of cancer treatment (chemotherapy, radiation), most insurers treat this differently from standard infertility. Many plans that exclude IVF cover egg or sperm freezing for cancer patients. Assert this distinction clearly.

Second opinion: If your insurer says your infertility diagnosis doesn't meet their criteria, obtain a second opinion from another reproductive endocrinologist who explicitly addresses the insurer's criteria.

Conclusion

Fertility treatment denials are among the most painful insurance disputes — but they are frequently overturned, especially when state mandates apply or when infertility is documented as a medical condition with a specific diagnosed cause. Fight back with strong medical evidence, cite applicable state mandates, and escalate to external review. Use ClaimBack at claimback.app to generate a professional appeal letter for your fertility treatment insurance denial.

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Related Reading:

• How to Write an Insurance Demand Letter
• How to Write a Second Insurance Appeal Letter
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies
• Top 10 Insurance Appeal Success Tips