Dysmenorrhea: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a 30-year-old female who has a history of menorrhagia and dysmenorrhea. She has an abnormal pelvic exam and pelvic ultrasound. Her uterus is enlarged and contains areas seen on the ultrasound, which are most likely myomas. She has failed medical management (birth control pills and pain medications). The patient has requested authorization for a hysterectomy. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary for treatment of the patient’s medical condition.The patient has an enlarged uterus. The ultrasound showed abnormalities in the echo pattern of the uterus, which the radiologist diagnosed as probable early myomatous degeneration. Since the patient’s uterus is enlarged to a 12-weeks size it is reasonable to assume that this enlargement is secondary to uterine myomas.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the medication, brand name Lo Loestrin Fe. The enrollee has a history of menstrual cramps since the age of 12, and has been on birth control since then. She has tried a number of different birth control pills and reports they have caused abdominal cramps, nausea and weight gain. A progress note describes an enrollee report that the generic version of Lo Loestrin Fe caused severe nausea, irregular menstruation and fatigue. She reports that Lo Loestrin Fe is the only medication that has been effective for her. The enrollee’s obstetrics and gynecology doctor is requesting authorization of Lo Loestrin Fe.

Where the denial was upheld

The patient is a 48-year-old female with chronic dysmenorrhea and premenstrual syndrome (PMS). She reports menses every 30 days with worsening menstrual cramps from 3 days prior and continuing to the third day of her menses. The dysmenorrhea has not been relieved by Darvocet, codeine, Naprosyn, ibuprofen or conventional oral contraceptives. The patient also reports premenstrual symptoms of depression and insomnia that have not responded to Effexor or over-the-counter preparations. The patient was evaluated by a gynecologist in January 2006. She had an ultrasound, which indicated normal uterus and ovaries. Following her evaluation, the patient was placed on Seasonale, which has allowed her to have a menstrual period every three months rather than every month. She apparently has found this to provide significant relief from her symptoms and has tolerated it well.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a hysterectomy.A review of the medical literature reveals that a simple hysterectomy is a reasonable definitive surgical management for menometrorrhagia and dysmenorrhea. However, studies indicate the importance of ruling out cervical and endometrial malignancies prior to proceeding with a hysterectomy by performing a colposcopy and endometrial biopsy (EMB). These procedures can be done in the office or as an outpatient procedure. The results of these procedures are needed to determine if proceeding with a simple hysterectomy is safe and appropriate for the management of the patient’s condition. The testing would allow for the provider to refer the patient for advanced care if the colposcopy or EMB uncovered cervical or endometrial cancer.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for dysmenorrhea was denied, the published record says the denial is worth fighting.