Largest insurer requiring preauthorization for some hysterectomies

In the latest volley in the ongoing controversy regarding the safety of some forms of hysterectomy, the country’s largest insurer will soon begin requiring prior authorization for many of the procedures. The action, taken by UnitedHealthCare, takes effect April 6, 2015 and does not apply to outpatient vaginal surgeries.

In a Medical Policy Bulletin to physicians and hospitals, UnitedHealthCare cites policy statements from AAGL and the American College of Obstetricians and Gynecologists as well as a Cochrane review and several meta-analyses to support its belief that “a vaginal approach to hysterectomy has fewer complications, requires a shorter hospital stay and is associated with better outcomes than a laparoscopic or abdominal approach.”

The CPT codes impacted by the new requirement, and listed in a Network Bulletin issued in January, apply to abdominal laparoscopic, vaginal, and laparoscopic-assisted vaginal hysterectomy. No prior authorization is needed for vaginal hysterectomies performed on an outpatient basis. If prior authorization is required, failure to obtain it will result in an administrative claim denial, according to the Bulletin.

The tightening of controls on hysterectomies comes in the wake of a warning from the Food and Drug Administration in November 2014 about the use of morcellators during laparoscopic hysterectomies because of concern about the potential for seeding of undetected uterine sarcomas. Morcellation is not performed during vaginal hysterectomy.

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In its coverage of the action by UnitedHealthcare, The Wall Street Journal speculated that because the company covers 40 million customers in the United States, it “could trigger broad changes in clinical practice.” 

Reflecting on the potential impact of the preauthorization guidelines, Contemporary OB/GYN Deputy Editor Jon I. Einarsson, MD, PhD, MPH, who is an expert in minimally invasive gynecologic surgery, pointed out that a vaginal procedure is the most cost-effective method of hysterectomy, but that mode of access is not suitable for all patients. “It’s unfortunate,” he said, “when an insurance carrier interferes with the physician-patient decision-making process.”

Dr. Einarsson also noted that there is no convincing evidence that vaginal hysterectomy requires a shorter hospital stay than a laparoscopic hysterectomy, since both are minimally invasive options. Data from randomized trials show that patients have significantly higher levels of pain in the immediate postoperative period after a vaginal hysterectomy as compared with the laparoscopic approach.

Regarding the controversy about morcellation, he said that during vaginal hysterectomy involving a large uterus, morcellation is commonly done vaginally with a knife. According to Dr. Einarsson, “The evidence shows that the higher mortality rate for morcellation is mostly associated with use of vaginal morcellation with a knife and not with use of traditional mechanical morcellators. Because any tissue disruption can potentially spread undetected cancers, we [at Brigham & Women’s] have been advocating for contained tissue extraction when morcellation of any kind is performed, but that is very difficult to accomplish with a vaginal approach, while very feasible when approaching a hysterectomy laparoscopically.” 

NEXT: What's the impact of bariatric surgery on pregnancy outcomes?

Pregnancy outcomes mixed after bariatric surgery

Bariatric surgery appears to lower risk of some complications in pregnancy-such as gestational diabetes-while increasing risk of other problems-such as small-for-gestational age (SGA)-according to a case-control study by researchers at the Karolinska Institute.

Published in The New England Journal of Medicine, the analysis looked at data from 670 births that occurred from 2006 to 2011 to women who had undergone bariatric surgery before pregnancy and who had their presurgery weight documented. Each post-bariatric surgery pregnancy was matched to 5 control pregnancies according to the mother’s presurgery body mass index (BMI) parity, smoking history, education level, age, and delivery year.  For controls, the BMI used was for early pregnancy.

The risks of having a large-for-gestational age (LGA) or SGA infant, neonatal death, major congenital malformations, stillbirth, preterm birth, and gestational diabetes were assessed.

More: Higher maternal BMI linked to fetal death, stillbirth

Pregnancies post-bariatric surgery were associated with a lower risk of gestational diabetes (1.9% vs. 6.8%; odds ratio, 0.25; 95% confidence interval [CI], 0.13 to 0.47; P<0.001) and of having an LGA infant (8.6% vs. 22.4%; odds ratio, 0.33; 95% CI, 0.24 to 0.44; P<0.001) than those among the controls. However, risks were higher in the surgery group of shorter gestation (273.0 vs. 277.5 days; mean difference −4.5 days; 95% CI, −2.9 to −6.0; P<0.001) and SGA infants (15.6% vs. 7.6%; odds ratio, 2.20; 95% CI, 1.64 to 2.95; P<0.001). The risk of preterm birth was not significantly different for the two groups (10.0% vs. 7.5%; odds ratio, 1.28; 95% CI, 0.92 to 1.78; P=0.15).

Risk of neonatal death or stillbirth was also higher in the pregnancies after bariatric surgery (1.7% versus 0.7%; odds ratio, 2.39; 95% CI, 0.98 to 5.85; P=0.06). No significant difference was found between the groups in the frequency of congenital malformations.

The investigators concluded that bariatric surgery did reduce the risk of certain pregnancy complications, but increased the risk of others. 

NEXT: How do contraceptive choices differ between female family planning providers and their patients?

Family planning providers more likely than their patients to use long-acting contraceptives

A nationwide survey of female family planning providers shows that they may be more likely to use long-acting reversible contraception (LARC) than their patients, according to a report in Contraception.

Doctors and advanced practiced clinicians aged 25 to 44 were included in the convenience sample polled by researchers from the Planned Parenthood Federation of America and the John H. Stroger, Jr. Hospital of Cook County, Chicago. Using an anonymous Internet-based survey, fielded from between April to May 2013, they were asked about their contraceptive choices. The participants were able to indicate use of multiple contraceptive methods and received a $25 gift card as an incentive.

A total of 488 surveys completed by the providers were considered eligible for analysis, of which 331 (67.8%) were from an individual using a contraceptive method. Their responses were compared to female respondents aged 25 to 44 from the 2011 to 2013 National Survey of Family Growth, with stratification for race-ethnicity, advanced degree, age, parity, and completion of childbearing.

Overall, 67.8% of the providers who responded were using contraception. They were far more likely to use an intrauterine device, implant, or a vaginal ring than were women in the general population and much less likely to use condoms or female sterilization.

Read more: Hormonal contraceptives linked to rare brain tumor

No significant difference was seen between the two groups in rates of partner vasectomy or usage of the pill. Overall, LARC use was significantly higher in the providers than in the general population (41.7% vs. 12.0%, P<.001). The results were consistent even when stratifying by variables including educational level and self-identified race/ethnicity.

Investigators concluded that the contraceptives of choice for female family planning providers widely differed from the general population, particularly in regard to adoption of LARC. They recommended that providers share the study’s findings with their patients to improve communication with their patients and their contraceptive knowledge.