Miscarriage: when insurers say no, reviewers often say yes

Where the denial was overturned

A 30-year-old female enrollee has requested reimbursement for emergency services for treatment of the enrollee’s miscarriage. Findings: The physician reviewer found that the patient is a 30-year-old female who initially presented to an Emergency Department with complaints of vaginal bleeding. She was 6.5 weeks pregnant at the time, and apparently was found to have a threatened abortion, which indicated that she was bleeding, but the pregnancy was still felt to be viable. She next presented to her gynecologist at nine weeks pregnant by dates, but the fetus was 8.5 weeks pregnant by ultrasound without a heartbeat. At that time, she was thus diagnosed as having a missed abortion (miscarriage) and her provider advised her to have a dilatation and curettage (D&C) reportedly to reduce the risk of infection or bleeding. She underwent a D&C completion of her miscarriage the following day.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.Findings: Three physician reviewers found the medical evidence supports a portion of the services at issue in this clinical setting. Per the American College of Obstetricians and Gynecologists, screening for thrombophilias is not recommended for a history of pregnancy loss. However, since the patient reported that she is of Ashkenazi Jewish descent, screening for Tay-Sachs should be offered. There is support for Tay-Sachs screening during pregnancy if either member of the couple is of Ashkenazi Jewish descent. Therefore, Tay-Sachs screening was likely to have been more efficacious than other available methods of evaluating this patient. However, the superior effectiveness of MTHFR testing has not been established.

Where the denial was upheld

Physician 1The patient is a 36-year-old woman who is six weeks pregnant. She has five prior spontaneous abortions ranging from five to seven weeks. Autoimmune workup revealed an elevated ANA and SSA/Ro, + dsDNA L, lupus anticoagulant. The patient lacks protective blocking antibodies. She has high natural killer cells. The patient’s provider has recommended IVIG therapy, aspirin, Lovenox and prednisone. The Health Plan has denied authorization and coverage for IVIG therapy indicating that it is considered investigational.The patient has had recurrent spontaneous abortions. She has evidence of autoimmune disorder and she lacks blocking antibodies. The patient may fit the category of antiphospholipid antibody syndrome though fetal losses are more typically greater than 10 weeks.

An enrollee’s medical history included recurrent pregnancy loss. The enrollee suffered miscarriages. She had operative hysteroscopy, polypectomy, and removal of possible products of conception and D&C (Dilation and Curettage). The enrollee’s provider indicated that due to the complex nature of the enrollee’s diagnosis, and the couple’s desire to become pregnant, the enrollee had the four laboratory services at issue performed to assess the cause of the enrollee’s recurrent pregnancy losses.Analysis and Findings: Three physician reviewers found that the American Society for Reproductive Medicine stated that routine testing of women with recurrent pregnancy loss (RPL) for inherited thrombophilias is not currently recommended.

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