Ob-Gyn Proc 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: An enrollee has requested authorization and coverage for ovarian and inner iliac vein embolization. Findings: The physician reviewer found that In a systematic review of ovarian vein embolization in 21 prospective case series and one randomized trial including 1,308 women, Daniels and colleagues reported that early substantial relief from pain was observed in approximately 75% of women undergoing embolization, and generally increased over time and was sustained. The authors concluded that embolization appears to provide symptomatic relief of chronic pelvic pain in the majority of women and is safe.

Where the denial was upheld

Patient 1: The patient is a 34-year-old female who has a history of pain in her right leg and vulva area, which occurs with ovulation and with the first day of her period. She apparently has a problem with varicose veins in the right lower extremity, which needs to be addressed and treated by the appropriate procedure. In June 2004, a pelvic MRI revealed “early filling and prominence of the right ovarian vein, which may indicate pelvic congestion syndrome.” The patient’s radiologist recommended an ovarian vein venography followed by embolization. The Health Plan has denied authorization for the requested procedure indicating it is considered investigational for treatment of the patient’s medical condition.

Nature of Statutory Criteria/Case Summary: An enrollee has requested vaginal hysterectomy with McCall vault suspension for treatment of the enrollee’s pelvic pain and menorrhagia. Findings: The physician reviewer found that upon review of the clinical notes and peer-reviewed medical literature, the requested procedure is not medically indicated in this clinical setting. The patient presented with a variety of different medical issues and had several pathologic changes noted upon examination and cytology. However, none of these medical issues rise up to the level that demonstrates the medical necessity of a vaginal hysterectomy. The patient presented with menorrhagia, uterine prolapse, pelvic pain, and anemia. She also had an abnormal Papanicolaou (Pap) smear. The patient reported concerns with family history of female cancers.

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 ob-gyn proc, then check the rights and deadlines that apply to your plan.