Uterine Fibroids denials in California external review
In the California DMHC record, independent physician reviewers decided 108 published external-review cases involving uterine fibroidsand overturned the plan’s denial in 33.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for uterine fibroids
| Treatment | Decisions | Overturned |
|---|---|---|
| Uterine Artery Embolization | 16 | 31.2% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 66 | 40.9% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 37 | 18.9% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 5 | 40% |
What the reviewers wrote
Where the denial was overturned
The enrollee requested reimbursement for laparoscopic ablation of uterine fibroids procedure (CPT code 58674). The enrollee has a history of intramural fibroids with abnormal uterine bleeding. An office visit revealed uterine fibroids, enlarged (16-week size), contour irregular and midline, mobile, and non-tender. The provider also noted leiomyoma and a pelvic mass. Pelvic ultrasound showed an anteverted, enlarged uterus. Also noted on the scan was a large, hypoechoic mass, indicative of a uterine fibroid and measuring 6.9 x 8.2 x 7.4 centimeters. The provider discussed a laparoscopic procedure, which uses radiofrequency energy to destroy the fibroid. Risks, benefits, and alternatives to the procedure were also discussed with the enrollee. The enrollee underwent the laparoscopic ablation procedure for abnormal uterine bleeding.
The patient is a 48-year-old female with problems related to dysfunctional menstrual bleeding since 2001. In addition, she is treated for severe rheumatoid arthritis and diabetes. In January 2006 the patient presented with the complaint of bleeding from December 2005 to the present; over a 5-day period, the bleeding was described as heavy enough to require changing a pad every 30 to 45 minutes. The provider’s workup included a normal endometrial biopsy, normal thyroid function, and PTT which was pending but also presumed normal. An ultrasound in January 2006 confirmed the presence of several small (less than 2cm) intramural uterine fibroids in addition to a 1cm submucosal fibroid. The patient was given a trial of progestins in an attempt to control her bleeding as she was not a candidate for oral contraceptives due to her history of diabetes.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services with a tertiary level of care physician who is dually board certified in both obstetrics and gynecology and reproductive endocrinology and infertility. Reproductive endocrinology and infertility medicine is a subspecialty of obstetrics and gynecology. As the name suggests, and according to the American Board of Obstetrics & Gynecology (ABOG), this subspecialty focuses on complex reproductive disorders. This may include the surgical management of these conditions. However, it should be noted that physicians in the field of general obstetrics and gynecology (OB/GYN) also manage a wide range of conditions on a routine basis.
The enrollee is requesting authorization and coverage for uterine fibroid removal surgery. Her back pain radiates to her leg and she has been treated with pain medications. On examination, she had a painful and reduced range of motion of the lumbosacral spine with an antalgic gait. A physical therapy consult diagnosed her with lumbar sprain/strain. A home exercise program was given. At a gynecology visit for abnormal vaginal bleeding, the treatment plan was for laboratory work and an endometrial biopsy. A pelvic ultrasound showed an enlarged uterus with a mass at the uterine fundus, consistent with a uterine fibroid, and a right ovarian cyst. She was started on Provera. The enrollee had a telephone consult with a different OB/GYN as she felt her concerns were not being addressed. She indicated she was interested in surgery for fibroid removal.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 uterine fibroids, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY