Consistency in insurance coverage for iatrogenic conditions resulting from cancer treatment including fertility preservation.

Insurance companies generally cover treatment for iatrogenic conditions that result from cancer treatment, including treatment for conditions that may be considered elective when “naturally” occurring (note that in this article, I am using the word “iatrogenic” to refer only to nonnegligent treatment-induced conditions). One notable exception is fertility preservation for iatrogenic infertility. In this brief article, I argue that for insurance companies to maintain consistency, they should cover fertility preservation treatment for female patients with cancer because it does not differ significantly from other treatments for iatrogenic conditions they currently cover for women, such as breast reconstruction after mastectomy and wigs for alopecia. (Although my focus in this article in on female fertility preservation, one could presumably make a similar argument that male fertility preservation should be covered by insurance.) One reason many insurance companies refuse to cover fertility preservation treatments, and infertility treatments more generally, is that they are often viewed as elective procedures, not medically necessary ones. When it comes to iatrogenic infertility, however, the controversy over whether fertility preservation is a medically necessary treatment should be moot because other so-called elective procedures are covered when they are iatrogenic, even if they are not covered when naturally occurring. Because my focus is on iatrogenic conditions—many of which, as I will discuss in this article, are generally not considered medical conditions when they are not iatrogenic—I put aside the debate about whether infertility should be classified as a “real” disease. One example of an iatrogenic condition typically covered by insurance is breast reconstruction after lumpectomy or mastectomy. Although having only one breast is rarely, and perhaps never, a naturally occurring condition, naturally occurring breast asymmetry is quite common. Most would not classify breast asymmetry as a medical problem that insurance should cover. However, when breast asymmetry results from a lumpectomy, surgery to achieve symmetry is usually covered regardless of whether the patient had symmetric breasts beforehand. This discrepancy in coverage between iatrogenic and naturally occurring breast asymmetry can be explained, at least in part, by looking at the harm principle through the lens of responsibility: because members of the medical profession caused the harm—something they are not supposed to do—the medical profession as a whole must take responsibility for mitigating the harm. (Another factor is the static understanding of the body that dominates medicine and science. Briefly, this is the idea that the body stays the same over time and disease is aberration that must be eradicated to restore the body to its natural and “normal” state. See Eckenwiler for a discussion of how this static understanding of the body has lead to women’s exclusion from clinical research trials.) Certain acts and laws were passed to institutionalize the medical realm’s responsibility for iatrogenic harms. For instance, the Women’s Health and Cancer Rights Act, which was passed in 1998, mandates that if health insurance companies cover the costs of mastectomy for cancer patients, then they must also cover the costs of breast reconstruction for mastectomy patients. Health care providers and insurance companies sometimes assume responsibility for iatrogenic harms by the way they code for billing. For example, breast reconstruction surgery after a mastectomy is coded as cancer treatment rather than under elective treatment. By allowing treatments for iatrogenic conditions to be subsumed into the larger category of disease treatment, insurance companies are tacitly accepting financial responsibility to cover these treatments. In addition to breast reconstruction surgery, there are other treatments that may not be covered by insurance when the disease is naturally occurring (in part because treatment is not seen as medically necessary), but are covered when iatrogenic; for example, wigs after cancer treatment are usually covered, whereas wigs for thinning hair or cosmetic reasons often are not. The same pattern of insurance coverage exists in the fertility/ infertility realm. Many insurance companies do not cover infertility or fertility preservation treatments for some of the following reasons: in/fertility treatments are experimental, they do not treat an underlying disease but rather produce a desired outcome (ie, a child), and they are an elective procedure, not a medical one. An exception to the lack of coverage is iatrogenic infertility. Although no formal studies have been done, there is anecdotal evidence that insurance companies will sometimes take financial responsibility for iatrogenic infertility. At the Northwestern University branch of the Oncofertility Consortium (www.oncofertility.northwestern.edu), a national, interdisciplinary initiative designed to explore the reproductive options for patients diagnosed with cancer or other serious diseases, female patients with cancer have the option to chose a fertility preservation method— embryo, egg, or ovarian tissue cryopreservation—before beginning cancer treatment. These fertility preservation treatments have been billed under a primary diagnosis of cancer and a secondary diagnosis JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 28 NUMBER 8 MARCH 1