Menopause denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Femring 0.05 mg/24 hour vaginal ring. As noted in the medical literature, postmenopausal female patients should be treated for their symptoms. HRT in the form of estrogen and progesterone is the most studied form with ample data on its advantages and disadvantages. The preferred form of estrogen is 17 beta-estradiol, which is structurally identical to the main estrogen produced by the ovary, and this is the estrogen contained in Femring. In this case, the patient’s provider reports that the benefits of using HRT outweigh the risks of discontinuation. The provider reported concern over the patient’s significant mood deterioration without Femring treatment.

The enrollee is requesting authorization and coverage for acupuncture service. The enrollee has menopausal symptoms; including hot flashes, night sweats and mood swings. The enrollee is trying to avoid hormone replacement therapy. The enrollee’s physician explained that all non-hormonal medical management options have been exhausted except gabapentin. The enrollee is not interested in gabapentin because of daytime sleepiness and dizziness. She is interested in acupuncture because she wants to rule out all possible treatment options prior to considering hormone replacement therapy. Scientific literature and studies have shown the efficacy of acupuncture for menopausal symptoms. Studies report a standardized six-week acupuncture treatment produced a fast and clinically relevant reduction in moderate-to-severe menopausal symptoms.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hormone based blood tests, two times per year for evaluation of the enrollee’s menopausal symptoms. Findings: The physician reviewer found that menopausal management is a very complex issue. Patients have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the patient may be experiencing and kept in context with any other medical issues they may have. Some of these more traditional therapies may include exercise, weight loss, topical lubricants and moisturizers, topical estrogens, stress reduction, biofeedback, counseling, and serotonin reuptake drugs.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone implants for treatment of the enrollee’s menopausal symptoms. The 3 physician reviewer found menopausal management is a complex issue. Patients have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and/or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the patient may be experiencing and kept in context with any other medical issues they may have. Some of these more traditional therapies may include, exercise, weight loss, topical lubricants and moisturizers, topical estrogens, stress reduction, biofeedback, counseling, and serotonin reuptake drugs.

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