Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Fibroid/ Adenomyoma. 
Treatment: Procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The insurer denied coverage for procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The denial is upheld. 

This is the case of a female patient with apparent 1.4-centimeter (cm) fibroid/ adenomyoma. The alternatives discussed were Sonata versus hysteroscopy. The patient's symptoms are not detailed. The magnetic resonance imaging (MRI) shows 5.3 x (times) 4.0 x 4.3 cm uterus. 

While the American College of Obstetricians and Gynecologists (ACOG) statement does confirm that Sonata is a reasonable option, and that the procedure may outweigh some surgical options, there is not a clear indication for procedural intervention given usual standards applied such as history of several personal visits with the gynecologist, physical examination including assessment of uterine size, notation of uterine enlargement with significant fibroids; cervical exam as well as assessment of hemoglobin (Hgb) status where possible menorrhagia affecting menstrual flow could be assessed. As to the question of proven improvement of health outcomes, there is good evidence in the already-cited articles and studies to suggest improvement of at least short-term health outcomes for the Sonata procedure, long term outcomes cannot be fully addressed until more data and longer-term outcomes are available. 

Other potential medical therapies include aromatase inhibitors, and selective estrogen receptor modulators (SERM), such as raloxifene or tamoxifen. There is little evidence supporting the use of these medications in the treatment for symptomatic uterine fibroids. Tranexamic acid has been approved for the treatment of abnormal and heavy uterine bleeding but has not been approved or shown to decrease the disease burden in uterine fibroids. 

The uterine dimensions were normal as described in imaging studies attached and there was a single possible fibroid. A patient with a 1.4 cm fibroid/adenomyoma is a better candidate for medical therapy and neither hysterectomy, laparoscopic ablation nor Sonata procedure given the absence of documented significant symptoms. She had not been offered observation which is certainly a viable option for a young patient with normal-sized uterus and singular apparent myoma or adenomyoma nor was she offered medical therapy (if there were significant symptoms which are not documented). Procedural intervention is usually not strongly indicated, given the limited time span of consultation and limited alternatives given. 

The procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus is not the best available treatment for this patient at this time. 

The requested procedure is not likely to be more beneficial than any other existing standard health service. 

In conclusion, there is lack of documented significant symptoms, lack of uterine enlargement, there is only one single apparent fibroid, and lack of confirmation of offering more medically directed alternatives including a period of observation. 
                                               
The carrier's denial of the procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus should be upheld.