April 16, 1999 .......... (retyped by Nancy Lee for posting, names/ID’s edited, on 9/1/99)

Nancy R. Lee
(street address)
(city, state, zip)

Re: Nancy Lee
Identification No.: (xxxxxxxxxx)
Group: (xxxxxxxxxx)

Dear Ms. Lee:

We have received your request for reconsideration regarding your denied request of a Uterine artery embolization for treatment of uterine fibroids. Thank you for your patience during our research of your inquiry.

The information you provided to us was extremely helpful in our research and processing of your reconsideration request. Your medical records and corresponding documentation were carefully reviewed by one of Intergroup’s Medical Directors. Intergroup must uphold the denial, because Uterine artery embolization for treatment of uterine fibroids remains an experimental/Investigational procedure based on criteria outlined in Foundation Health Medical Policy. This procedure is not a community standard of care for Uterine Leiomyomata. Medical criteria for abdominal hysterectomy are met based on Dr. (my gyne)’s examination. Please contact Dr. (my gyne) for further management.

If you feel that your request has been denied inappropriately, you have the right to a reconsideration of our decision. For a detailed explanation of the complaint and appeal procedure, please refer to your Evidence of Coverage. If you have any questions, please feel free to contact Customer Service at 1-800-289-2818 at Ext. 7440 or (520) 290-7440.

Please refer to your 1997 Evidence of Coverage, Exclusions and Limitations, number 14 on page 87.

Experimental/Investigational Procedure
Experimental and/or Investigational medical, surgical or other experimental health care procedure, services or supplies. Experimental and/or Investigational procedures, services or supplies are those which, in the judgement of Intergroup:

* Are in a testing stage or in field trials on animals or humans;
* Do not have the required final federal regulatory approval for commercial distribution for the specific indications and methods of use assessed; are not in accordance with generally accepted standards of medical practice; or have not yet been shown to be consistently effective for the diagnosis or treatment of the Member’s condition.

If the decision reached as a result of this Informal Reconsideration does not meet with your satisfaction, you have the right to a Formal Appeal. Your request for a formal appeal must be received within sixty (60) days after receiving Intergroup’s response to your Informal Reconsideration. Please notify Intergroup, in writing, of your desire for a Formal Appeal using the following address:

Intergroup of Arizona
Attn.: Member Inquiry Supervisor
930 N. Finance Center Dr.
Tucson, AZ 85710

We will confirm the receipt of your request within five (5) days. Your request will be reviewed, a decision made, and notification sent to you and your provider within thirty (30) days.

We take your concerns very seriously, because we use them to identify areas within our system that need attention. You are our most important source of information, in Intergroup’s continuous quality improvement processd. We use your ideas to improve and ensure quality service for all our members. We have a line dedicated to our State of Arizona members, please call 1-800-977-7484 if your require any additional assistance.

(appeals specialist)
Grievance and Appeals Specialist
Member Inquiry Department