Based upon the information provided on August 4, 2005, the documentation provided dies not indicate Ms. K has been unable to obtain or sustain a successful pregnancy through reasonable, less costly, medically appropriate infertility treatment for which coverage is available under their plan. Thus, based upon this medical review, it does not appear Ms. K is eligible for the infertility benefits acailable through the ---- plan provisions.
Ok, we were expecting it not to be covered, especially right at first. What I wasn't expecting was the subtle implication that fertility treatment would be covered, just not the treatment we chose. So, today I called the insurance company and talked to R who was very nice, although completely unhelpful. He said that my doctor also got a copy of the letter, and therefore I would have to ask him (although she's a she) about what other treatments would be medically appropriate. When I reiterated that the letter doesn't say what would be covered, he said that she would have to determine what other treatments were appropriate and send another request for predetermination of benefits. To clarify, I said "So basically, we just have to guess what might be covered and wait for someone to decide whether it will be covered or not?" And he said (and this is the good part) "Yes, basically" Ok, so, there are LOTS of things you *could* try to get pregnant. I can't think of many other options that would work for us. I guess I will ask about it at our next appointment, but I don't have high hopes. My best bet is that since I seem to not be ovulating on my own, they may be able to re-request benefits on that basis and perhaps then at least the follicle scans and clomid might be covered. It's worth a try, but I *hate* that they make you keep doing more paperwork over and over again instead of just telling you what's covered. I mean, I realize that they can't cover every possibility in a set of strictly followed rules, but how about some general guidelines?! Ugh!
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