Laparoscopy denials in California external review

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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diagnostic and operative laparoscopy, treatment of endometriosis, lysis of adhesions, isthmocele repair, hysteroscopy with possible resection, possible appendectomy, possible cystoscopy and proctoscopy (standard excision of pelvic peritoneal endometriosis, laparoscopic bilateral ureterolysis, for laparoscopic excision of endometriosis of uterosacral ligaments, laparoscopic excision of endometriosis from the bladder, laparoscopic excision of endometriosis from intestines, except rectum, laparoscopic procedure, appendix, laparoscopic excision of endometriosis/fibrosis of rectum/rectovaginal septum, laparoscopic suspension of the ovaries, laparoscopic neuroplasty of the nerves, and laparoscopic excision of endometriosis/fibrosis of cervix).

Where the denial was upheld

A 47-year-old female enrollee has requested authorization and coverage for laparoscopy, surgical, with vaginal hysterectomy with removal of tube(s) and/or ovary(s) for treatment of the enrollee’s pelvic pain and abnormal bleeding. Findings: The physician reviewer found that based on review of the available records, the patient has a significant history of abnormal bleeding and pelvic pain. In general, the incidence of abnormal uterine bleeding increases as women approach the end of their reproductive years. In this regard, perimenopausal women are not unlike their perimenarchal counterparts. In perimenopausal women, the onset of anovulatory cycles, which are a frequent cause of the abnormal bleeding, represents a continuation of declining ovarian function.

Nature of Statutory Criteria/Case Summary: The patient has been treated for chronic pain for several years. She has been treated with physical therapy, nerve blocks, acupuncture, and medication therapy. The patient has undergone multiple surgical interventions. The records noted that she is status post lysis of adhesions. She has had some response to hormone replacement and requires chronic narcotic use for pain control. The patient has requested authorization and coverage for deep excision laparoscopic surgery. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has undergone multiple prior surgeries without benefit.

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