How to Appeal for IVF Coverage

In the United States, many infertility patients find it difficult to pay for treatment such as IVF, especially since IVF is not often covered by medical insurance. Some states mandate infertility coverage. You can check this list or this one to see if your state mandates coverage.

In 2004, my insurance company covered the rarely used GIFT and ZIFT treatments, but did not cover IVF. Since GIFT and ZIFT are uncommonly used, more invasive, less effective, more expensive, and more risky than IVF, I was able to appeal to my insurance company for IVF coverage.

I am providing a kit that can be used to make a similar appeal. These instructions are specific to residents of the United States, and for those whose insurance covers GIFT and/or ZIFT, but not IVF; if you do not fit into this category, perhaps you can still use these steps as a starting point for your own tailored appeal. Here are the steps to follow:

1.) Call your insurance company and specifically ask which infertility tests and treatments are covered. Be sure to make a note of the date and time of your call, and the name of the customer service representative that you talk with. You may need this information as part of your appeal. Some insurance companies require that you file the appeal within a certain number of days after you learn that coverage is not provided.

2.) Visit the website of your health insurance company or call them to determine the appeals process.

My appeals process consisted of three steps:

• First level appeal: I sent a simple letter asking that IVF coverage be substituted for GIFT/ZIFT coverage.

• Second level appeal: I sent a fact-filled, more detailed letter to the appeals committee.

• Meeting with the committee: I presented my case in-person to the committee (I simply read my letter and answered some questions).

3.) Be prepared to send a simple letter to the appeals committee. I know, trying to conceive is one cruel waiting game after another...but wait! While you are waiting for the appeal letter to be answered, there are other things you can do:

a.) Look at the latest CDC ART report to get a listing of the IVF clinics in your area. Find an email address for each one (you will need to locate a web site for each clinic to get the email address). Send an email to the clinic asking if they perform GIFT or ZIFT, and if they no longer perform these procedures, why not? You will need this information for your appeals letter, so save each response. I made a special folder in my Inbox for the responses.

b.) Download my appeal letter and start filling in the blanks with information specific to your appeal (enter your name, your address, and the address of the appeals committee.) I am also providing a PDF version, in case you are unable to open the Word document. There's also a section for IVF success statistics for clinics in your area. Visit the CDC ART report statistics again for this information. Enter this information in table 1 of the document.

As you receive email responses from the various clinics you wrote to, you will also need to replace the clinic responses in Appendix A with the responses you received. (I left the responses in my template letter, just so you can get the idea. Please remove my responses.) Enter the name and city of each clinic, along with the date you received the email response.

4.) Once you receive your response from the appeals committee, follow the rest of the steps of your appeals process. If your appeals process includes an in-person meeting, be prepared to provide the cost of IVF at the clinic you plan to use.

Through the appeals process, I was awarded coverage for one IVF treatment up to $7000. My IVF actually took placed during the appeals process, so it happened that they provided me with a check to reimburse the cost of treatment. My friend followed the same process (she actually gave me the idea), and I believe she was awarded coverage for multiple IVF cycles, because that's what she requested. So, I guess it doesn't hurt to specifically request coverage for multiple cycles. You may also consider asking for coverage of your prescriptions if they are not normally covered.


If you are able to successfully appeal for coverage, please let me know. It is a very empowering feeling! Do it, today!