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 with a history of menorrhagia and uterine fibroids. She has been on norethindrone and continued to have heavy bleeding. She had an endometrial biopsy that was inadequate as no endometrial tissue was recovered. Ultrasound showed multiple myomas. The physician discussed options with the patient including oral contraception, Depo-Provera, Mirena intrauterine device (IUD), dilation and curettage (D&C) Novasure ablation, myomectomy, hysterectomy, and radiofrequency ablation of fibroids. The patient would like to proceed with laparoscopic radiofrequency ablation of fibroids and D&C hysteroscopy with Novasure ablation. 

Laparoscopic radiofrequency ablation (Lap-RFA), known as the Acessa procedure is used to treat women with symptomatic myomas not interested in future fertility. It was approved by the US (United States) Food and Drug Administration (FDA). 

Based on a randomized, prospective study, compared to myomectomy, Lap-RFA is associated with significantly lesser intraoperative blood loss, shorter procedure and hospitalization times, lesser consumption/use of disposable and reusable surgery equipment, reduced health care resource utilization, and faster return to work through 3 months post treatment.

A meta-analysis of 8 studies showed that all subscales of quality of life improved significantly, and most of the changes remained stable in long-term follow-up. The overall reintervention rate was 4.39% (percent) and the median uterine volume reduction was 69.17 cm3 (centimeters). The overall procedure-related adverse events rate was 1.78% and patients missed an average of 4.35 days of work. 
In conclusion, laparoscopic radiofrequency ablation therapy is an efficacious way to treat small-sized and nonpedunculated symptomatic uterine fibroids, providing stable long-term symptom relief and quality of life improvement with a low risk of adverse events and reintervention and just a few days of missed work. 

However, this patient had an inadequate endometrial biopsy. In other words, it is unclear if the fibroids are causing the bleeding or if there is another pathology. In addition, the provider is requesting coverage for 2 procedures: Novasure and Acessa. The Novasure alone should be able to control the heavy bleeding without the need for procedure code 58674, laparoscopy surgical ablation of uterine fibroids. In summary, this patient is not a good candidate for the Acessa procedure, and the requested procedure is not more beneficial than the standard treatments available for this patient.

The requested outpatient surgery services (code 58674 Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency) is not medically necessary in this case.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Laparoscopic surgery ablation for uterine fibroids (CPT code 58674) has final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

Laparoscopic surgery ablation for uterine fibroids (CPT code 58674) is not the best available treatment for this patient at this time.

The requested service 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.