Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollees medical history included recurrent pregnancy loss. The enrollee suffered miscarriages. She had operative hysteroscopy, polypectomy, and removal of possible products of conception and D&C (Dilation and Curettage). The enrollees provider indicated that due to the complex nature of the enrollees diagnosis, and the couples desire to become pregnant, the enrollee had the four laboratory services at issue performed to assess the cause of the enrollees recurrent pregnancy losses.Analysis and Findings: Three physician reviewers found that the American Society for Reproductive Medicine stated that routine testing of women with recurrent pregnancy loss (RPL) for inherited thrombophilias is not currently recommended. American College of Obstetricians and Gynecologists has reached the same conclusion and states that screening for inherited thrombophilias is not recommended for women with a history of fetal loss or adverse pregnancy outcomes that includes abruption, preeclampsia, or fetal growth restriction because there is insufficient clinical evidence that antepartum prophylaxis with unfractionated or low-molecular-weight heparin prevents recurrence in these patients. Because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, including an increased risk of VTE, screening for either MTHFR mutation analyses or fasting homocysteine levels is not recommended. (ACOG Practice Bulletin No. 197). In this case, the laboratory tests in question were drawn. These comprised a large number of autoimmune tests, above and beyond testing needed to assess for the antiphospholipid syndrome (APS), as well as testing for several inherited thrombophilias. Most authorities believe that patients with RPL should be assessed for APS, but this testing can be limited to an assessment for the lupus anticoagulant, anticardiolipin antibodies, and beta-2 glycoprotein I antibodies. The services at issue in this case, however, involved testing that was not needed to assess for APS, and involved screening for inherited thrombophilias that is not recommended. Therefore, the services at issue were not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested reimbursement for four laboratory tests performed. Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, quantitative, not otherwise specified; (2) F2 prothrombin, coagulation factor II, e.g., hereditary hypercoagulability gene analysis, 20210G>A variant; (3) F5 coagulation factor V, e.g., hereditary hypercoagulability gene analysis, Leiden variant; and (4) MTHFR 5,10-methylenetetrahydrofolate reductase, e.g., hereditary hypercoagulability gene analysis, common variants, e.g., 677T, 1298C were not likely to be more beneficial for the patient than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 are board certified in obstetrics and gynecology and 3 is board certified in obstetrics and gynecology, with subspecialty certification in reproductive endocrinology and infertility and are actively practicing. The reviewers are experts in the treatment of the enrollees 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.