Pelvic Pain denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 16-year-old female with a history of pelvic/groin pain. She has migratory pain in the lower abdominal quadrants and groin, right side greater than left. The pain is constant and always present, but can increase to as high as 7/10. She also complains of shoulder pain. She has a history of chronic bilateral frontal headaches, reported as migraines. She has undergone extensive workup in the past for the cause of her pain. Workup included multiple negative laboratory examinations, CT scans and abdominal pelvic ultrasounds. It also included extensive physical evaluations by multiple physicians. The patient has been evaluated and treated by a psychotherapist who feels no significant psychopathology is present. She has taken multiple medications including large doses of neuropathic pain medications such as Neurontin, trileptal, lidocaine and Ultram.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the abdomen and/or Tylenol 30 mg/300 mg tablets, one tablet every eight hours as needed for pain, dispense 90 tablets every 30 days. As noted in the medical literature, MRI is supported for the detection of “diffuse or focal hepatic pathology, benign and malignant bile duct pathology, pancreatic tumors, inflammatory bowel disease and rectal tumors”. Additionally, MRI can detect multiple causes of pelvic pain, such as vascular and neoplastic causes. This patient’s pelvic pain has been extensively evaluated without an explanatory finding despite imaging with a CT scan of the abdomen and pelvis as well as a colonoscopy.

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