Menopausal Symptoms denials in California external review
In the California DMHC record, independent physician reviewers decided 17 published external-review cases involving menopausal symptomsand overturned the plan’s denial in 5.9%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 11.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested Estrogel for treatment of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient has severe menopausal symptoms. She indicates that she had adverse effects from oral estrogen and when she tried the estradiol patch. The current medical evidence supports the requested medication in this clinical setting. The treatment with transdermal estrogen gel is an appropriate option for this patient, and potentially safer than oral therapy. The Health Plan requires that the patient try and fail an oral option and an estrogen patch prior to approval of Estrogel. It appears that she meets this criteria. In addition, she has used the Estrogel with good results.
Where the denial was upheld
A 60-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Tri-Est (Estrogel) 0.3gm/progesterone 3.0gm/testosterone 0.06gm/propylene glycol 2.90ml/HRT base 25.10gm compounded hormone replacement therapy (topical medication). The Health Plan has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollee’s menopausal symptoms. Findings: Three physician reviewers found that the patient has been using a compounded hormone preparation topical cream containing an estrogen, progesterone, and testosterone for menopausal symptoms. Per the submitted documentation, she has tried oral PremPro, but discontinued it due to side effects. The patient reported that she has a family history of strokes, heart disease, and breast cancer.
A 69-year-old female enrollee has requested compounded topical cream (estradiol and progesterone) for treatment of her menopausal symptoms. Findings: Three physician reviewers found that compounded drugs are agents that are prepared, mixed, assembled, packaged, or labeled as a drug by a pharmacist. Unlike drugs that are approved by the U.S. Food and Drug Administration (FDA) to be manufactured and sold in standardized dosages, compounded medications often are custom made for a patient according to a physician’s specifications. The steroid hormones most commonly compounded include dehydroepiandrosterone, pregnenolone, testosterone, progesterone, estrone, estradiol, and estriol.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 menopausal symptoms, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY