Menorrhagia: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee’s parent has requested reimbursement for blood coagulation factor five gene analysis. The records indicate that the patient’s provider recommended blood coagulation factor five gene analysis to assess whether the patient had a problem with abnormal clotting prior to the initiation of oral contraceptives to manage her menorrhagia. The provider noted that the patient’s mother has a history of Factor V Leiden mutation. All of the laboratory tests performed are instrumental in clotting and are considered within the standard of care for patients with potential clotting problems. As noted in the medical literature, the factor V Leiden mutation predisposes patients toward hypercoagulability. In this case, the patient has a first-degree relative, her mother, who has the factor V Leiden mutation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lysteda. Findings: The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Lysteda is approved by the U.S. Food and Drug Administration (FDA) for the treatment of heavy menstrual bleeding. A review notes that, “Tranexamic acid represents an option for treatment of women with HMB (heavy menstrual bleeding) who do not desire or should not use hormonal treatment. Tranexamic acid is an antifibrinolytic agent that competitively blocks the conversion of plasminogen to plasmin, thereby reducing fibrinolysis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested vaginal hysterectomy with McCall vault suspension for treatment of the enrollee’s pelvic pain and menorrhagia. Findings: The physician reviewer found that upon review of the clinical notes and peer-reviewed medical literature, the requested procedure is not medically indicated in this clinical setting. The patient presented with a variety of different medical issues and had several pathologic changes noted upon examination and cytology. However, none of these medical issues rise up to the level that demonstrates the medical necessity of a vaginal hysterectomy. The patient presented with menorrhagia, uterine prolapse, pelvic pain, and anemia. She also had an abnormal Papanicolaou (Pap) smear. The patient reported concerns with family history of female cancers.

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.

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