Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroid. 
Treatment: Uterine Artery Embolization. 

The insurer denied Uterine Artery Embolization. 
The health plan's determination is upheld. 

This patient is a female. The patient reports heavy menses and has had several emergency room (ER) visits for this. She has undergone three iron infusions to keep up with blood loss. The patient was sent to interventional radiology to have an evaluation for embolization of her fibroids, which they believe can relieve her heavy bleeding. A computed tomography (CT) scan noted a uterine fibroid with a small amount of free fluid in the pelvis. A pelvic ultrasound noted a uterine fibroid. The patient had one prior pregnancy that underwent an induced abortion and a live birth by vaginal delivery.
The patient's medical issues included depression, alcoholism, drug addiction, eating disorder, hearing disorder, headache, mental illness, migraine, thyroid disease, hypothyroidism, vertigo, seasonal allergies, acne, and attention deficit hyperactivity disorder. The patient's examination was noted for a normal size uterus with normal shape and consistency. There was no tenderness or mass appreciated. The patient was counseled that her heavy menses requiring iron infusions to prevent anemia, were likely due to a large submucous myoma and embolization was under consideration to possibly cure this problem. A wet mount was normal, and vaginitis was excluded. The office ultrasound was noted to demonstrate a 4 centimeter (cm) submucous myoma. A magnetic resonance imaging (MRI) was completed of the pelvis for the indication of dysfunctional bleeding with uterine fibroids and measured the uterus to be 7.8 times (x) 12 x 6 centimeter (cm). The endometrium was 1 cm. In the posterior fundus, there was a 4 x 3.6 x 4 cm myoma. 

At issue is the medical necessity of Uterine Artery Embolization. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Uterine Artery Embolization is not medically necessary for this patient. 

In this case, the requested uterine artery embolization for heavy menstrual bleeding and fibroid is not medically necessary for this patient given a lack of workup prior to procedure and institution and failure of medical therapy. The patient was noted to have a single myoma in a submucous location in the fundus measuring 4 cm. The patient was noted to have received intravenous (IV) iron infusions. There have been no attempts to control the bleeding with medical interventions. The clinical trial of care would require at least three months on oral contraceptives, progesterone, or Mirena intrauterine device (IUD) for control of bleeding. If this were not successful, a three-month trial of tranexamic acid for control of bleeding would then be executed. The medical evaluation would also include an assessment of the endometrium and exclusion of pathology in planning any intervention to exclude hyperplasia or carcinoma. Menstrual blood loss is reduced by 40-50% in women who used cyclic combined oral contraceptives (OC). The effectiveness of combined OC's may be enhanced by extended cycle or continuous therapies that reduce the number of total bleeding episodes. Extended cycle and continuous combined OC's as well as many of the progestin-only contraceptive options (progestin-only pills, depot medroxyprogesterone acetate (DMPA), progestin contraceptive implants, and levonorgestrel intrauterine system) reduce overall bleeding days and may achieve amenorrhea in women. Contraceptive steroids (estrogen and progestin combinations and progestin alone) are widely used for the control of abnormalities of menstruation. These agents generally are first-line therapy for control of abnormal bleeding and painful menstruation in women with and without leiomyoma.
Therefore, the requested health service/treatment of Uterine Artery Embolization is not medically necessary.