Rupture Of Membranes: when insurers say no, reviewers often say yes
In 15 published external-review decisions involving rupture of membranes, independent physician reviewers overturned the insurer’s denial 0% of the time.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the AmniSure test for evaluation of the enrollee’s pregnancy. Findings: 2/3 of the physician reviewers found that as noted by the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of ROM is traditionally made based on patient history and clinical examination including a speculum evaluation of the vagina and cervix. Typically, the patient history, with its description of leakage of fluid, can be of help to rule in or rule out the diagnosis. This coupled with a sterile speculum examination to provided direct visualization to help better evaluate vaginal/cervical secretions, to evaluate the pH of any secretions, and to perform a microscopic examination for cervical ferning complete the examination.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing. According to the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of rupture of membranes (ROM) is traditionally made based on patient history and clinical examination including a speculum evaluation of the vagina and cervix. Typically, the patient history, with its description of leakage of fluid, can help to confirm or rule out the diagnosis. This is coupled with a sterile speculum examination to provide direct visualization to evaluate for pooling, to evaluate the pH of any secretions, and to perform a microscopic examination for cervical ferning complete the examination. From a review of the medical records, this patient had a high risk course and was complaining of additional moisture and discharge.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 rupture of membranes was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY