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Yanxin Lu
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---
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type: insurance
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category: patient_confirmation_statement
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person: Yanxin Lu
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date: 2025-08-13
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provider: Center for Male Reproductive Medicine
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source: 806298980_AUTH-1358040_Progyny_Statement.pdf
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---
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# Progyny Patient Confirmation Statement — Treatment
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## Contact Information
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**For Providers:**
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auths@progyny.com | 888.461.5062
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**For Members:**
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Contact your dedicated Patient Care Advocate
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---
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## Patient Information
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| Field | Value |
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|---|---|
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| Employer | Meta |
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| Progyny Patient Name | Yanxin Lu |
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| Birthdate | 10/17/1989 |
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| Progyny Patient Member ID | 806298980 |
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| Progyny Subscriber Name | Yanxin Lu |
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| DOB | 10/17/1989 |
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| Progyny Subscriber Member ID | 806298980 |
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---
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## Authorization Details
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| Field | Value |
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|---|---|
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| Authorization Number | AUTH-1358040 |
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| Valid From | 08/13/2025 - 11/11/2025 |
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| Practice | Center for Male Reproductive Medicine |
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| Clinic Location | Center for Male Reproductive Medicine (Los Angeles CA) |
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| CPT Code(s) | 99499-25 RU Diagnostics and Workup |
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| Smart Cycle Value | 0.00 |
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---
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## Notes
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Fertility services are administered through Progyny. A list of covered services can be found in the patient's member guide and provider manual. Financial responsibility applies dependent upon patient's medical plan. Any service not included in the authorization for this treatment should be billed to the patient's medical plan unless covered under a separate authorization. The clinic is the guarantor for all in-cycle bloodwork and monitoring services. Please note that outside monitoring is not covered. Call Progyny Provider Relations at 888.461.5062 with any questions.
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Transfer cycle authorizations are approved for a single embryo transfer only unless approval from Progyny's Medical Advisory Board is obtained.
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**Preimplantation Genetic Testing (PGT) Laboratories:** Please use an approved lab as listed on Progyny.com/labs. Please list Progyny as payer and include the Authorization number for In-Network participating labs.
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Authorization ID for PGT-A is the same as the Authorization ID listed on this Patient Confirmation Statement. Authorization ID for PGT-SR or PGT-M must be requested through Provider Relations.
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---
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## Progyny Claims Submission
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| Field | Value |
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|---|---|
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| EDI Payer ID | PROGY |
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| Payer Name | Progyny, Inc. |
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| Claim Address | 505 South Lenola Rd, Suite 231 Moorestown, NJ 08057 |
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*Coverage is based upon eligibility at time of service.*
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---
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type: receipt
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category: payment_receipt
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person: Yanxin Lu
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date: 2025-10-03
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provider: Progyny / ReproSource Fertility Diagnostics
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source: Progyny_09192025_09062025ELT0022.pdf
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---
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# Progyny Payment Receipt
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**Progyny — Smarter Fertility Benefits**
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**Date:** October 03, 2025
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---
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## Provider Information
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| Field | Value |
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|---|---|
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| Provider | Progyny |
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| Address | 1359 Broadway 2nd FL, New York, NY 10018 |
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| Email | collections@progyny.com |
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| Phone | (833) 499-1479 |
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| Account # | 806298980 |
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| Patient | YANXIN LU |
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---
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Thank you for your payment of $209.67 to Progyny for healthcare services outlined below:
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## Service Line Items
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| Date of Service | Service | Charges | Insurance | Patient | Balance |
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|---|---|---|---|---|---|
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| 08/18/2025 | 82397 ; CHEMILUMINESCENT ASSAY TEST — Patient: YANXIN LU — Physician: REPROSOURCE FERTILITY DIAGNOSTICS | $69.18 | ($62.26) | $0.00 | $6.92 |
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| 08/18/2025 | 88184 ; SPERM DNA FRAGMENTATION — Patient: YANXIN LU — Physician: REPROSOURCE FERTILITY DIAGNOSTICS | $809.09 | ($728.18) | $0.00 | $80.91 |
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| 08/18/2025 | 88185 ; SPERM DNA FRAGMENTATION — Patient: YANXIN LU — Physician: REPROSOURCE FERTILITY DIAGNOSTICS | $1,031.00 | ($927.90) | $0.00 | $103.10 |
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| 08/18/2025 | 89051 ; SPERM DNA FRAGMENTATION — Patient: YANXIN LU — Physician: REPROSOURCE FERTILITY DIAGNOSTICS | $135.84 | ($122.26) | $0.00 | $13.58 |
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| 08/18/2025 | 89261 ; SPERM DNA FRAGMENTATION — Patient: YANXIN LU — Physician: REPROSOURCE FERTILITY DIAGNOSTICS | $51.57 | ($46.41) | $0.00 | $5.16 |
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---
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## Payment Information
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| Date Paid | Card Ending | Confirmation | Amount Paid |
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|---|---|---|---|
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| 10/03/2025 | Visa 6118 | 276411048801 | $209.67 |
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| | |
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|---|---|
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| **Total Paid** | **$209.67** |
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| **Balance Due** | **$0.00** |
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---
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*Powered by PatientPay*
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documents/medical/werthman/Progyny_09192025_09062025ELT0022.pdf
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documents/medical/werthman/Progyny_09192025_09062025ELT0022.pdf
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documents/medical/werthman/Yanxin Lu SA & DFI_08_2025.md
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documents/medical/werthman/Yanxin Lu SA & DFI_08_2025.md
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---
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type: lab_report
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category: semen_analysis_and_dfi
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person: Yanxin Lu
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date: 2025-08-18
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provider: Center for Male Reproductive Medicine / ReproSource Fertility Diagnostics
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source: Yanxin Lu SA & DFI_08_2025.pdf
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---
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# Advanced Semen Report & Semen Analysis
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## Page 1: ReproSource Advanced Semen Report
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**The ReproSource — Fertility Diagnostics**
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200 Forest Street, 2nd Floor, Suite B
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Marlborough, MA 01752 USA
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Tel: 800.667.8893 USA only
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Fax: 781.935.3068
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CLIA#: 22D0884531
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---
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### Patient Information
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| Field | Value |
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|---|---|
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| Patient | Lu, Yanxin |
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| Gender | M |
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| Age | 35Y |
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| Date of Birth | 10/17/1989 |
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| Specimen | 00598276 |
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| Reported | 08/26/2025 |
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| Received | 08/20/2025, Time: 09:50 |
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| Collected | 08/18/2025, Time: 15:15 |
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### Clinician Information
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| Field | Value |
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|---|---|
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| Clinician | Philip Werthman MD |
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| Phone | 1-310-277-2873 |
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| Fax | 1-310-286-2139 |
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| Address | Center For Male Reproductive Medicine, 2080 Century Park East, Suite 907, Los Angeles, CA 90067 |
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---
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### Overview
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| Test | Value | Normal | Borderline | Abnormal | Result |
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|---|---|---|---|---|---|
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| DFI | 3 | 0-20 | 20-30 | >30 (60 >60) | **Normal** — DNA integrity |
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| OSA | 1.4 | 0-3.8 | 3.8-4.4 | >4.4 (9 >9) | **Normal** — Damage from free radicals/reactive oxygen species (ROS) |
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| HDS | 6 | 0-15 | | >15 (30 >30) | **Normal** — Levels of decondensed DNA (eg immature sperm) |
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---
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### Patient Results & Interpretation
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| Test Name | Normal Range | Unit | Result | Comment |
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|---|---|---|---|---|
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| DFI — DNA Fragmentation Index | <20 | % | **3** — Normal | Predicted Success: Natural: normal, IUI: normal, IVF: normal, ICSI: normal. Higher DFI scores correlate to lower success rates in natural or IUI attempts at pregnancy. Abnormal DFI results suggest the consideration of advancing directly to IVF or ICSI, treatments that lower the DFI score, and/or consultation with a urologist specializing in fertility. |
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| Oxidative Stress Adduct | <3.8 | uM | **1.4** — Normal | The OSA test directly measures sperm damage from oxidative stress by quantifying the presence of "adducts," molecules in semen covalently modified by free radicals/reactive oxygen species. Men from 955 infertile couples demonstrated significantly higher results compared with 20 fertile controls (Fig 1, p<0.05). Low results have unclear clinical significance at this time. |
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| HDS — High DNA Stainability | <15 | % | **6** — Normal | The HDS Score provides supplementary information regarding the percent of cells with highly-staining DNA, and can be abnormal when high levels of immature sperm cells are present. |
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**Additional comments:** *(none)*
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---
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### References
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1. Tirado E, Marquette M, Musto JD, Leader B The association of aging, oxidative stress and DNA integrity in human spermatozoa. *American Society of Andrology 2010*. Abstract.
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2. Evenson DP, Darzynkiewicz Z, Melamed MR. Relation of mammalian sperm chromatin heterogeneity to fertility. *Science*. 1980;210(4474):1131-1133. doi:10.1126/science.7444440
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3. Bungum M, Humaidan P, Axmon A, et al. Sperm DNA integrity assessment in prediction of assisted reproduction technology outcome. *Hum Reprod*. 2007;22(1):174-179. doi:10.1093/humrep/del326
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4. Evenson DP, Jost LK, Marshall D, et al. Utility of the sperm chromatin structure assay as a diagnostic and prognostic tool in the human fertility clinic. *Hum Reprod*. 1999;14(4):1039-1049. doi:10.1093/humrep/14.4.1039
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5. Spano M, Bonde JP, Hjollund HI, Kolstad HA, Cordelli E, Leter G. Sperm chromatin damage impairs human fertility. The Danish First Pregnancy Planner Study Team. *Fertil Steril*. 2000;73(1):43-50. doi:10.1016/s0015-0282(99)00462-8
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6. Erenpreiss J, Bungum M, Spano M, Elzanaty S, Orbidans J, Giwercman A. Intra-individual variation in sperm chromatin structure assay parameters in men from infertile couples: clinical implications. *Hum Reprod*. 2006;21(8):2061-2064. doi:10.1093/humrep/del134
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The above tests were developed and their analytical performance characteristics have been determined by ReproSource Fertility Diagnostics. They have not been cleared or approved by the U.S. Food and Drug Administration. These assays have been validated pursuant to the CLIA regulation and are used for clinical purposes.
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**Laboratory Director:** (CLIA) Vivekananda Datta, M.D., Ph.D.
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(c) 2010 ReproSource ASR 2.0 Clin 20220309
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---
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## Page 2: Center for Male Reproductive Medicine — Semen Analysis
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**CENTER FOR MALE REPRODUCTIVE MEDICINE**
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Lab Director: Philip Werthman, M.D., P.C.
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2080 Century Park East, Suite 907 Los Angeles, CA 90067
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(310) 277-2873 Fax (310) 286-2139
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---
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### Specimen Information
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| Field | Value |
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|---|---|
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| Patient Name | Yanxin Lu |
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| DOB | SA 250818 (handwritten) |
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| Date of Specimen | 8.18.25 |
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| Time Collected | 3:12 |
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| Age of Specimen | 50 min |
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| Spouse/Partner Name | *(blank)* |
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| Results sent to | *(blank)* |
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### Specimen Use
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- [x] Complete Semen Analysis
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- [ ] Count only
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- [ ] Insemination prep
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- [x] DFI/OSA
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- [ ] Culture and sensitivity
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- [ ] Freeze
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**Days since last ejaculation:** 2
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**Any portion lost?** NO
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**Comments:** Progyny (handwritten)
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---
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### Patient Results
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| Parameter | Result | Normal Range (WHO, 2006) | Normal Range (WHO, 2010) |
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|---|---|---|---|
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| Volume (cc) | 5.L (approx 5) | 2.0 - 5.0 cc | 1.5 - 6 cc |
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| Count (mil/cc) | h (not clearly legible) | > 20 mil/cc | >15 mil/cc |
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| Motility (%) | 56 7. (approx 56%) | > 50% | > 32% |
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| Grade | 2+/3 | 3 - 4 | 3 - 4 |
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| pH | 8.0 | 7.2 - 8.0 | >= 7.2 |
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| Round Cells (lpf) | 0-1 | < 10/lpf | < 1 |
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| Viscosity | N (Normal) | Normal | Normal |
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| Agglutination | d (none/mild) | None | None |
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| Normal Morphology (%) | 3 | > 30% | > 4% (strict criteria) |
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| Head Defects (%) | *(not filled)* | | |
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| Midpiece (%) | *(not filled)* | | |
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| Tail (%) | *(not filled)* | | |
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| Total Abnormal (%) | *(not filled)* | | |
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**Insemination Prep:** *(blank)*
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**Tech:** *(signature present)*
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