Fibroid Removal denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic surgical radiofrequency ablation (RFA) of uterine fibroids. Uterine fibroids are the most common benign tumors of the female reproductive tract causing symptoms such as heavy bleeding, bulk symptoms, pain, and increased urinary frequency. Some patients prefer minimally invasive approaches for fibroid treatment with desire for uterine conservation. Both uterine artery embolization and ultrasound guided radiofrequency ablation (RFA) are options for uterine-sparing minimally invasive techniques. In a recent systematic review of nonresective treatments for uterine fibroids published by Taheri and colleagues, the authors found that the pooled fibroid volume reductions at six months after RFA and uterine artery embolization were 70% and 54%, respectively.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical removal of fibroids (laparoscopic myomectomy). The records document that this patient has a history of heavy bleeding and pelvic pain in the setting of a fibroid uterus. The patient has requested treatment with a uterine sparing procedure. On review of the peer-reviewed medical literature and current guidelines, treatment with myomectomy is a reasonable option for the treatment of this patient’s pelvic pain. Per the American College of Obstetricians and Gynecologists (ACOG) recommendations, uterine fibroids are the leading indication for hysterectomy.

Where the denial was upheld

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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acessa laparoscopic radiofrequency ablation procedure. Researchers concluded that, “laparoscopic radiofrequency ablation therapy is efficacious for small-sized and non-pedunculated symptomatic uterine fibroids.” Based on this review, this patient is not a suitable candidate for the Acessa laparoscopic radiofrequency ablation procedure. The patient’s fibroid is pedunculated and measures 6.9 x 4.8 x 7.1 cm. In addition, the patient previously underwent magnetic resonance guided treatment of her myomas, and there is a lack of data demonstrating that subsequent radiofrequency in this clinical setting is safe and effective. The patient has heavy bleeding and symptoms related to her fibroid uterus. Palpation of the myoma causes 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 Fibroid Removal, then check the rights and deadlines that apply to your plan.