Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hormone based blood tests, two times per year for evaluation of the enrollees menopausal symptoms. Findings:  The physician reviewer found that menopausal management is a very 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 documentation indicates that the patient has been prescribed bioidentical compounded hormonal therapy for her menopause complaints. There is no mention of other management options, such as whether the patient has tried any other medicinal and nonmedicinal form of therapy and the response to that therapy.  Although prior to menopause testosterone contributes to energy levels and healthy sexual function in women, 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, lack of emotional intimacy, conflict, stress, or mood concerns. This patient has requested twice yearly testing of her hormone levels to help adjust her medical management.  In order to successfully manage these particular menopause issues, the multilayers of concerns/factors need to be addressed. It is not simply measuring a twice yearly hormone level. The American College of Obstetricians and Gynecologists (ACOG) has noted that evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy.  Per the medical evidence, customized compounded hormones pose additional risks, as these preparations have variable purity and potency and lack efficacy and safety data.  As noted by ACOG, there is a lack of evidence to support increased safety or efficacy for individualized hormone therapy regimens based on serum, urinary, or salivary testing.  Hormone levels within the body are typically secreted in a pulsatile fashion and can vary widely throughout the course of a given day.  They can be affected by many factors, including sleep, stress, activity, time of day, and other concurrent medications. These widely varying markers are typically not reliable and are not used to determine management of menopausal symptoms.  Additionally, if treatment is initiated for symptom control, subjective improvement in symptoms is the therapeutic endpoint, and there is no need to assess hormone levels. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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.