Fibroids: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a 48-year-old female with problems related to dysfunctional menstrual bleeding since 2001. In addition, she is treated for severe rheumatoid arthritis and diabetes. In January 2006 the patient presented with the complaint of bleeding from December 2005 to the present; over a 5-day period, the bleeding was described as heavy enough to require changing a pad every 30 to 45 minutes. The provider’s workup included a normal endometrial biopsy, normal thyroid function, and PTT which was pending but also presumed normal. An ultrasound in January 2006 confirmed the presence of several small (less than 2cm) intramural uterine fibroids in addition to a 1cm submucosal fibroid. The patient was given a trial of progestins in an attempt to control her bleeding as she was not a candidate for oral contraceptives due to her history of diabetes.

The patient is a 48-year-old female with a history of polymenorrhea, pelvic pain, and significant fibroids. The submitted records indicate that on ultrasound the uterus is enlarged to 13.7 x 4.2 x 4.9 cm with a 3.4 cm fundal fibroid and a 6 cm pedunculated fibroid; in addition, there is present a 0.6 cm cyst adjacent to the endometrium. The records provided do not document the extent of the patient’s bleeding, whether she has become anemic as a result of her bleeding or whether she has experienced pelvic pain. However, based upon other documentation submitted, it appears the patient has had long-term polymenorrhea, which has resulted in anemia. In addition, the patient indicates she has pelvic pain, which causes recurrent work absences.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic hysterectomy (vaginal, laparoscopically-assisted) for treatment of the enrollee, who has a history of excessive uterine bleeding and severe pelvic pain. Findings: The physician reviewer found that the patient has a history of pelvic pain, anemia and menorrhagia. Her evaluation for these complaints included a pelvic ultrasound significant for a fibroid uterus, and normal endometrial biopsy. Her gynecologist has recommended a laparoscopic hysterectomy (vaginal, laparoscopically-assisted). The patient has a significant history of abnormally heavy bleeding and pelvic pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for laparoscopic total hysterectomy for treatment of the enrollee’s uterine fibroids, ovarian cyst and pelvic pain syndrome. Findings: The physician reviewer found that Uterine fibroids are the most common solid pelvic tumors in women and the leading indication for hysterectomy. The two most common symptoms for which women seek treatment for this diagnosis are abnormal bleeding and pelvic pressure. Symptoms and treatment options are affected by the size, number, and location of the leiomyomas. Furthermore, acute pelvic pain is a common presenting complaint in women. The differential diagnosis includes gynecologic, urologic, musculoskeletal, gastrointestinal, vascular and metabolic disorders. A thorough history and physical examination is necessary to narrow the possible diagnoses and focus the work-up.

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 fibroids was denied, the published record says the denial is worth fighting.