How to appeal an IVF insurance denial in District of Columbia
How to appeal a denial
- Internal appeal — you have 180 days from the denial to file. The plan must decide within 30 days (before service) or 60 days (after service); 72 hours if urgent.
- External review — available for at least 4 months after the final internal denial, for medical-necessity and "experimental" denials (PGT-A, ICSI, step therapy). An independent reviewer decides within 45 days. Contractual exclusions are not eligible for external review — those go to the regulator as a complaint.
- Regulator — D.C. Department of Insurance, Securities and Banking (DISB). DISB Health Benefits Plan Members Bill of Rights external review (D.C. Code § 44-301.07) File a complaint. Copy the regulator on every appeal letter; clinics report it speeds things up.
If your plan is self-funded, skip the state regulator: your appeal runs under ERISA and complaints go to the U.S. Department of Labor's Employee Benefits Security Administration.
Common denial reasons and what to argue
- Step therapy / 'try IUI first' — cite the payer's own bypass criteria (age 38+, tubal factor, stage III–IV endometriosis, severe male factor) and the state law's language (which does not permit an IUI requirement).
- 'Experimental' (PGT-A, ERA, ICSI without male factor) — eligible for external review; ask the clinic for a medical-necessity letter. Success is limited for PGT-A.
- Cycle cap reached — check how the plan counted cycles (a cancelled cycle may or may not count) against the statute's definition.
- Not infertile / definition — see the single-and-LGBTQ+ page; cite the statute's definition.
- Medication routing — many denials are the wrong pharmacy or a missing prior auth, not a coverage decision. Ask the specialty pharmacy to re-run with prior auth.
- AI-only review — several states now bar insurers from denying on medical necessity without a physician's individualized review; ask in writing whether AI was the sole basis.