Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids.

Treatment: procedure code 58674, laparoscopy surgical ablation of uterine fibroids.

The insurer denied coverage for procedure code 58674, laparoscopy surgical ablation of uterine fibroids.

The denial is upheld.

The patient is a female who presented to her gynecologist with complaints of menorrhagia and uterine fibroids. A pelvic ultrasound revealed three fibroids, with all intramural and one containing a submucosal component. Multiple treatment options were discussed including hormonal treatment, hysterectomy, endometrial (ablation) and laparoscopic radiofrequency ablation. The patient declined hysterectomy and chose laparoscopic radiofrequency ablation. Laparoscopic radiofrequency ablation is planned. 

The medical records reveal that the patient wishes to leave the option of maintaining fertility "open" and has chosen radiofrequency volumetric thermal ablation (RFVTA). Options for minimally invasive uterus-sparing alternatives for the treatment of uterine fibroids, within the standard of care include myomectomy and uterine artery embolization. The Acessa device is a new FDA (Food and Drug Administration) approved minimally invasive treatment for uterine fibroids that uses radiofrequency energy to destroy fibroid tissue. The novel use of radiofrequency ablation under laparoscopic and intra-abdominal ultrasound guidance to treat patients with symptomatic myomas was first introduced years ago. This has prompted the development of the proposed procedure device (Acessa) which carries out laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation of uterine myomas in symptomatic women. The key feature to using laparoscopic ultrasound lies in the inherent and immediate proximity of the transducer to the target (fibroid), allowing the use of higher frequencies with significantly increased resolution. In addition, the versatility and mobility of laparoscopic ultrasound permits direct imaging from multiple directions and angles. 

The patient has symptomatic uterine fibroids and TFA (transcervical fibroids ablation) is recommended. The American College of Obstetrics and Gynecology, in its Practice Bulletin, states: "Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation and are counseled about the limited available data on reproductive outcomes...Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation and are counseled about the limited available data on reproductive outcomes. Radiofrequency ablation (RFA) can be delivered by a laparoscopic, transvaginal, or transcervical approach, using ultrasound guidance to induce coagulative necrosis in targeted uterine leiomyomas. All of the approaches are similarly effective in reducing uterine leiomyoma volume and in improving quality of life metrics, but the laparoscopic approach has been studied the most rigorously". 

Therefore, this patient is a good candidate for procedure code 58674, laparoscopy surgical ablation of uterine fibroids. The scientific evidence in the peer-reviewed literature supports a result of improvement in health outcome and has final approval from the appropriate regulatory bodies for this diagnosis. The adverse risks are not increased over standard treatment/services.

However, procedure code 58674, laparoscopy surgical ablation of uterine fibroids is not the best available treatment for this patient at this time. There is no evidence in the literature to support the procedure as more effective than other procedures within the standard of care. It is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of procedure code 58674, laparoscopy surgical ablation of uterine fibroids should be upheld.