Hysterectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Standard Review A transgender male enrollee has requested authorization and coverage for a hysterectomy. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s gender dysphoria. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Nature of Statutory Criteria/Case Summary: There is support in the literature for the requested procedure in this clinical setting.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hysterectomy for treatment of the enrollee’s uterine prolapse. Findings: The physician reviewer found that the services at issue were medically necessary in this clinical setting. The patient had a complete workup for the etiology of her symptoms. The provider recommended surgical management for treatment of this patient’s uterine prolapse after the workup was completed and the physiologic/pathologic changes that were contributing to her symptoms were more clearly defined. Based on the records, the degree of rectoenterocele prolapse at the time of this patient’s surgery would not have been resolved with medical management or pelvic floor physical therapy. The use of a pessary may have helped alleviate some of her symptoms temporarily, but it would not have resolved all of her symptoms completely.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hysterectomy (CPT Code 58550). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s chronic uterine pain. The submitted documentation does not support the medical necessity of the requested services. In this patient’s case, an appropriate gynecologic workup was required due to the patient’s history chronic pelvic/abdominal pain. This patient did not appear to have a complete gynecologic workup for the etiology of the symptoms presented by the gynecologist nor did the records indicate that there were any consultations for the etiology of the patient’s pain from the primary care provider or a provider with sub-specialty certification in gastroenterology, general surgery, or urology.

A 43-year-old female enrollee has requested reimbursement for hysterectomy services provided in Lima, Peru. The Health Plan has denied this request indicating the services at issue were not required on an urgent basis. Findings: The physician reviewer found that this case involves a female patient with a history of uterine fibroid, menometrorrhagia and anemia. The patient presented to her provider with complaint of menometrorrhagia with two days of heavy bleeding and clotting. The provider noted the patient had been seen by her gynecologist who recommended either ablation or hysterectomy secondary to fibroid uterus. The patient subsequently traveled to Peru. Prior to her leaving for Peru, her physician increased her iron and recommended she have additional labs performed when she returned.

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