April 16, 1999 .......... (retyped by Nancy Lee for posting, names/IDs edited, on 9/1/99)
Nancy R. Lee
(city, state, zip)
Re: Nancy Lee
Identification No.: (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 Intergroups 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 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 Members condition.