Endometriosis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diagnostic and operative laparoscopy, treatment of endometriosis, lysis of adhesions, isthmocele repair, hysteroscopy with possible resection, possible appendectomy, possible cystoscopy and proctoscopy (standard excision of pelvic peritoneal endometriosis, laparoscopic bilateral ureterolysis, for laparoscopic excision of endometriosis of uterosacral ligaments, laparoscopic excision of endometriosis from the bladder, laparoscopic excision of endometriosis from intestines, except rectum, laparoscopic procedure, appendix, laparoscopic excision of endometriosis/fibrosis of rectum/rectovaginal septum, laparoscopic suspension of the ovaries, laparoscopic neuroplasty of the nerves, and laparoscopic excision of endometriosis/fibrosis of cervix).

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Belbuca Film or Hysingla Extended-Release Tablets.At issue in this case is whether the requested Belbuca Film is medically necessary for the treatment of the patient’s medical condition. If not, are Hysingla extended-release tablets medically necessary to treat the patient’s medical condition? The 2016 Centers for Disease Control (CDC) guidelines on opioid therapy for non-cancer pain state, “When opioids are started, clinicians should prescribe the lowest effective dosage.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for platelet rich plasma. In gynecology, the research on platelet rich plasma therapy is very limited and primarily anecdotal. A recent publication presents a comprehensive review of the use of platelet rich plasma in various gynecologic applications including treatment for refractory endometrium, Asherman's syndrome, poor ovarian response, wound healing, lichen sclerosus, female sexuality issues, vesicovaginal fistula, stress urinary incontinence, and bladder pain syndrome. While the authors acknowledge the potential of platelet rich plasma for these applications, they highlight the need for further studies to confirm its effectiveness and explore its application in other disorders.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopically assisted vaginal hysterectomy (LAVH). Findings: The physician reviewer found that a hysterectomy is appropriate for pelvic pain after a comprehensive evaluation has been performed, including evaluation by pain specialist and mental health evaluation, as indicated. Furthermore, if investigations have not identified specific etiology of symptoms, individuals are encouraged to undergo uterine sparing treatments, hormonal treatment, or utilize gonadotropin releasing analogues, analgesics, antidepressants, and physical therapy. In the case of endometriosis, a hysterectomy is appropriate when the endometriosis has been confirmed by histology, laparoscopic visualization, or identification of endometrioma.

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 endometriosis, then check the rights and deadlines that apply to your plan.