Abnormal Uterine Bleeding denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysteroscopy dilation and curettage polypectomy procedure.An UpToDate review on hysteroscopy notes that the procedure is performed for the evaluation or treatment of the endometrial cavity, tubal ostia, or endocervical canal in women with (among other indications) abnormal premenopausal or postmenopausal uterine bleeding and endometrial thickening or polyps. An UpToDate review on how to approach abnormal uterine bleeding states that hysteroscopy provides direct visualization of the endometrial cavity. The review notes that in an operative setting, hysteroscopy allows targeted biopsy or excision of lesions identified during the procedure.

Findings: The physician reviewer found that The patient has requested authorization and coverage for total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s). As noted in one study, “Abnormal uterine bleeding (AUB) is defined as bleeding coming from the uterus that is abnormal in frequency, duration, volume, and/or regularity.” One study noted that patients with endometriosis or adenomyosis experience a variety of problems, including poor quality of life due to severe pain or abnormal uterine bleeding. Per the records provided for review, this patient presents with a history of abnormal uterine bleeding and iron deficiency anemia. The patient’s provider has recommended treatment with a total abdominal hysterectomy and ovarian cystectomies versus bilateral salpingectomies and oophorectomy.

Where the denial was upheld

A 47-year-old female enrollee has requested authorization and coverage for laparoscopy, surgical, with vaginal hysterectomy with removal of tube(s) and/or ovary(s) for treatment of the enrollee’s pelvic pain and abnormal bleeding. Findings: The physician reviewer found that based on review of the available records, the patient has a significant history of abnormal bleeding and pelvic pain. In general, the incidence of abnormal uterine bleeding increases as women approach the end of their reproductive years. In this regard, perimenopausal women are not unlike their perimenarchal counterparts. In perimenopausal women, the onset of anovulatory cycles, which are a frequent cause of the abnormal bleeding, represents a continuation of declining ovarian function.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total laparoscopic hysterectomy surgery. Findings: The physician reviewer found that Abnormal uterine bleeding (AUB) is a common gynecologic problem and can result in anemia and interfere with daily activities. The goals of initial therapy are to correct the underlying etiology (if present and feasible), improve quality of life, prevent an episode of acute uterine bleeding, prevent (or treat) anemia, establish a regular bleeding pattern, and prevent endometrial hyperplasia/carcinoma. For most patients with AUB and no known etiology, estrogen-progestin contraceptives or the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) are recommended.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving abnormal uterine bleeding, then check the rights and deadlines that apply to your plan.