July 27, 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:

Thank you for taking the time to share your concerns about your request for Intergroup to approve a uterine artery embolization for treatment of uterine fibroids and for your patience during Intergroup’s review of your request.

The Committee would like to thank you for helping to coordinate Pam, your patient advocate, and Dr. (my IR) in presenting your case. In addition, one of our Medical Directors contacted a Gynocology Specialist at the University of Arizona regarding the procedure. Following the presentation on July 27, 1999 the Appeals Committee thourougly (sic) reviewed all of the issues and determined to uphold the denial because uterine artery embolization for treatment of uterine fibroids, according to criteria outlined in Foundation Health Medical Policy, is considered an Experimental/Investigational procedure.

For further information regarding this denial, please refer to your State of Arizona Evidence of Coverage, Section, “Exclusions and Limitations,” it states (sic); “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 this decision does not meet with your satisfaction, you have the right to an External Independent Review of your case. Your request for a Review must be received within thirty (30) days after you receive Intergroup’s decision on your Formal Appeal. Please notify Intergroup, in writing, of your desire for an External Independent Review 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, and will respond with a resolution within thirty (30) days. It is important that you are aware that the decision of this External Independent Review is final and binding. This is the highest level in Intergroup’s appeal process.

(appeals specialist)
Grievance and Appeals Specialist
Intergroup Inquiry Research Department