How to appeal an IVF insurance denial in Virginia
Virginia currently has no law requiring IVF or fertility coverage. HB 328 (signed May 13, 2026) adds fertility diagnosis, iatrogenic-infertility treatment, and up to 3 IVF cycles per lifetime to Virginia's essential health benefits benchmark plan for plan year 2028 — affecting individual and small-group ACA plans, pending CMS approval.
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 — Virginia State Corporation Commission, Bureau of Insurance. Virginia external review (Va. Code § 38.2-3556 et seq.) via the Bureau of Insurance 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 / prior-treatment requirements — check your plan's own Summary Plan Description or clinical policy for its step-therapy criteria and ask the payer for its bypass criteria (age 38+, tubal factor, stage III–IV endometriosis, severe male factor are common).
- Benefit limits — if your employer voluntarily covers fertility care, the denial is governed entirely by the plan document, not state law; ask for the exact clause the denial relied on.
- '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.
- 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.