Even if you don’t have infertility treatment coverage, your insurance might still pay for mTESE surgery for azoospermia!!
Excluded from coverage? Or not?
Here’s what my coverage documents say is excluded from coverage:
“Health services and associated expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment. This exclusion does not apply to services required to treat or correct underlying causes of infertility.”
Diagnostic vs. Treatment
mTESE surgery is not a fertility treatment. It is a diagnostic surgery. Diagnostic means your doctor doesn’t know what causes the azoospermia or oligospermia or whatever symptom you have for which your doctor is performing the procedure. Yes, extracting sperm is part of it, but the big thing the lab is doing is getting you a diagnosis of what’s happening in the testicles.
It’s like going to the dermatologist for a suspicious mole. All the doctor can tell from looking at it is that it doesn’t look quite right. To find out what it is, they biopsy it and send it to a lab.
The mTESE is the same thing. The doctor can tell from the semen analysis and hormone blood work that something isn’t quite right, but to find out what it is, a biopsy is needed. Surgical extraction of the biopsy and sending that biopsy to a lab where they can diagnose you is something your insurance should pay for. If that lab happens to be an Andrology Lab where they can simultaneously extract some sperm for IVF with ICSI, then so be it! From the doctor and insurance perspective, the purpose is to give a diagnosis. Azoospermia is not a diagnosis, it is a symptom.
Now, if your insurance documents state that both treatment and diagnostics for infertility are excluded, then you might be up a creek and have to pay cash. But if your documents only state that treatments are excluded, then you’re probably in luck.
If you’ve already had one mTESE and you’re hoping your insurance will pay for a second one, I think that’s probably a gray area. Second mTESE biopsies are less likely to be about diagnostics and more likely to be about fertility treatment.
Finding your coverage
To find out what kind of coverage you have, you can call your insurance company and ask. But I always like to look at the documents myself and try to understand.
To get to this document that essentially said I have coverage for infertility diagnostics but not infertility treatments, I went online to my health insurance company (United Healthcare) and logged into my account. I went to “Coverage Documents” then chose “Medical Certificate.” It was a 130 page document. Your insurance company might have a different name for it, but probably something similar. Then I just searched for “infertility.” It was in a section called Reproduction.
When your doctor won’t bill your insurance for you
This is really, really common. Don’t let it stop you from collecting from your insurance company!
Some doctors won’t do it because the insurance companies won’t reimburse them for the amount of time they spend searching for sperm. They only reimburse for the procedure, not the time. And trust me, you want the doctor to take as much time as he needs!
Others won’t do it because they assume that it’s a fertility procedure and that your insurance won’t pay. (See above why they are wrong!)
Others just don’t want to argue with insurance companies about reimbursement. Or worry about getting you to pay when the insurance company won’t, especially if the doctor wasn’t able to find sperm.
Regardless of the reason, don’t let that intimidate you! You can still bill the insurance company yourself!
All you need to do is download form CMS 1500, fill it out, and submit it to your insurance company. The doctor’s office should provide you with the procedure code (called a CPT code) and the diagnosis code (called ICD9 or ICD10 code).