Total Abdominal Hysterectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 48-year-old female with a history of polymenorrhea, pelvic pain, and significant fibroids. The submitted records indicate that on ultrasound the uterus is enlarged to 13.7 x 4.2 x 4.9 cm with a 3.4 cm fundal fibroid and a 6 cm pedunculated fibroid; in addition, there is present a 0.6 cm cyst adjacent to the endometrium. The records provided do not document the extent of the patient’s bleeding, whether she has become anemic as a result of her bleeding or whether she has experienced pelvic pain. However, based upon other documentation submitted, it appears the patient has had long-term polymenorrhea, which has resulted in anemia. In addition, the patient indicates she has pelvic pain, which causes recurrent work absences.

Findings: The physician reviewer found that The patient has requested authorization and coverage for total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s). As noted in one study, “Abnormal uterine bleeding (AUB) is defined as bleeding coming from the uterus that is abnormal in frequency, duration, volume, and/or regularity.” One study noted that patients with endometriosis or adenomyosis experience a variety of problems, including poor quality of life due to severe pain or abnormal uterine bleeding. Per the records provided for review, this patient presents with a history of abnormal uterine bleeding and iron deficiency anemia. The patient’s provider has recommended treatment with a total abdominal hysterectomy and ovarian cystectomies versus bilateral salpingectomies and oophorectomy.

Where the denial was upheld

The patient has requested authorization and coverage for total abdominal hysterectomy. The American College of Obstetricians and Gynecologists (ACOG) recommends use of non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, and intrauterine devices for the treatment of menorrhagia. The ACOG specifically noted that “surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management.” Surgical intervention can include endometrial ablation or vaginal hysterectomy or total laparoscopic hysterectomy with or without bilateral salpingectomy. Current medical literature indicates that minimally invasive surgery is associated with a lower complication rate for well selected patients. This patient’s records document prior treatment has included medroxyprogesterone.

A 31-year-old female has requested a total abdominal hysterectomy for treatment of her uterine fibroids. Findings: The physician reviewer found that there is no clear relationship between the patient’s fibroid and her bleeding, since the fibroid was not noted to be submucosal (in the uterine cavity). As noted in American College of Obstetricians and Gynecologists (ACOG) guidelines, uterine leiomyomata usually require treatment only when they cause symptoms, lead to urinary obstruction or appear to contribute to infertility. The ACOG guidelines note that not all bleeding is caused by leiomyomata, and other causes of abnormal bleeding in the presence of leiomyomata should be ruled out. Based on the information provided, the patient has not undergone other workup to see if there is any other etiology for her abnormal bleeding.

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