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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone implants for treatment of the enrollees menopausal symptoms. The 3 physician reviewer found menopausal management is a complex issue. Patients have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and/or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the patient may be experiencing and kept in context with any other medical issues they may have. Some of these more traditional therapies may include, exercise, weight loss, topical lubricants and moisturizers, topical estrogens, stress reduction, biofeedback, counseling, and serotonin reuptake drugs. In this case, the chart indicates several menopause complaints, but no mention of management options. The records do not document whether the patient has tried other medicinal and nonmedicinal forms of therapy and the response to that therapy. Prior to menopause, testosterone contributes to energy levels and healthy sexual function in women. However, many other factors also play a role in postmenopausal lethargy, depression and sexual dysfunction. These factors include decreased estrogen levels, vaginal dryness, medication side effects, chronic health conditions, loss of a spouse or partner, lack of emotional intimacy, conflict, stress, or mood concerns. For successful management, these types of concerns/factors need to be addressed. The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion Number 532 noted the evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy. ACOG noted the scientific evidence does not demonstrate that compounded hormones are more efficacious or safer than standard hormone therapy. Compounded bioidentical hormone are not recommended as first-line therapy. In sum, hormone implants were not likely to be of greater benefit than other treatment modalities. Final Result: The 3 reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert 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.Physician reviewer number two is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert 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.Physician reviewer number three is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert 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.