Uterine Artery Embolization denials in California external review

What the reviewers wrote

Where the denial was overturned

SummaryThe patient is a 51 year old female with uterine fibroids and symptoms of menorrhagia, dysmenorrhea and pelvic pressure and has undergone a previous uterine artery embolization (UAE). She is asking for authorization of for a repeat UAE procedure. The Health Plan denied her request based upon a determination that a second UAE is considered investigational. Two of the three physician reviewers concluded that the proposed treatment is clinicaly appropriate and the Health Plan denial should be overturned. The third review determined that the denial should be upheld. Analysis and FindingsClinical Facts: There is evidence, according to a progress note, that the patient has had a previous myomectomy, the date is unknown. The patient’s provider noted the uterus was at least 12 weeks in size on pelvic examination. This was confirmed with pelvic ultrasound, with a 14cm length observed.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for uterine fibroid embolization with ultrasound guidance. The records provided for review document that this patient presented to her provider with symptomatic uterine fibroids. The provider charted that the patient underwent evaluation with MRI, which demonstrated an anteverted uterus. The MRI also showed a large heterogeneous pedunculated fibroid arising from the anterior upper corpus/fundal region. The patient underwent uterine fibroid embolization with ultrasound guidance. Uterine fibroids are the most common benign tumors of the 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.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for occlusion of blood vessels in the uterus and/or magnetic resonance imaging (MRI) of the lower pelvis with and without contrast.The records indicate that this patient has a diagnosis of pelvic pain. However, there is a lack of documentation that the patient has undergone a complete work-up for chronic pelvic pain. The initial work-up for a patient with chronic pelvic pain involves a detailed history, physical examination, and targeted investigations to identify potential causes and guide treatment. The assessment can include laboratory tests, imaging studies, and potentially laparoscopy. A biopsychosocial approach is essential, considering physical factors and psychological aspects that may contribute to or exacerbate a patient’s pain.

A 42-year-old female has requested a repeat right-sided uterine artery embolization for treatment of her uterine fibroids. Findings: Two physician reviewers found that the patient has a history of diabetes and is status post kidney-pancreas transplant. Her provider noted that the she had episodes of complete urinary retention related to large fibroids during the past two years. The provider noted that a non-hysterectomy approach was preferred in light of the patient’s transplant status. The submitted documentation noted that the patient has to self-catheterize for complete bladder emptying. Uterine fibroid embolization is based upon the hypothesis that reduction of myometrial arterial blood flow will result in infarction of fibroids and control of symptoms.

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 Uterine Artery Embolization, then check the rights and deadlines that apply to your plan.