Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspareunia, pelvic pain and menorrhagia. 
Treatment: Laparoscopy surgical with total hysterectomy for uterus 250g or less with removal of tubes and/or ovary(s)-58571. 

The insurer denied the Laparoscopy surgical with total hysterectomy for uterus 250g or less with removal of tubes and/or ovary(s)-58571. 
The denial is upheld. 

The patient is a G2P2 (two pregnancies, two births) female. She has a history of dyspareunia, pelvic pain and menorrhagia. She consulted her attending gynecologist for the complaints. 

An MRI (magnetic resonance imaging) of the pelvis revealed a normal uterus and ovaries. A pelvic examination was normal except for several intramural fibroids < [less than] 2cm (centimeters). An endometrial biopsy was performed was normal. Laparoscopic hysterectomy was recommended. Coverage of the procedure has been denied by the Health Plan on the basis of lack of medical necessity, due to lack of documentation of trial and failure of conservative treatment such as pain medication or hormone therapy, and lack of documentation of a diagnostic laparoscopy to document endometriosis. The denial is being appealed. 

No, the requested health service is not medically necessary. 

The medical records and medical literature were thoroughly reviewed. The pathophysiologic reasons for abnormal uterine bleeding include structural causes, such as endometrial polyps or fibroids, and infectious causes, such as chronic endometritis, as well as "idiopathic" abnormal prostaglandin metabolism, abnormalities in other cellular events, or adenomyosis. If anatomic abnormalities are not present, long-term hormonal treatment may be used to regulate bleeding, reduce menstrual blood loss and the dysmenorrhea that may be associated with the abnormal bleeding. For women with menorrhagia, administration of oral progestins (for example norethindrone and medroxyprogesterone) or oral contraceptives, as attempted in this patient, may significantly reduce menstrual blood loss by 40% to 50%. Pain may be reduced with this treatment as well. These agents are often required to obviate the need for endometrial ablation or hysterectomy. 

Because of its reduced intensity and risks, medical therapy should be offered before surgical intervention unless it is otherwise contraindicated. There is no evidence that this treatment was provided for this patient. In addition, there is no evidence that the endometrial cavity was appropriately evaluated. 

The American College of Obstetrics and Gynecology, in its Practice Bulletin, states: "Surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. Avoidance of anemia, reduction of excessively heavy bleeding, and increased, though imperfect, predictability of bleeding are appropriate goals to attempt to achieve with medical therapy. Surgical options include hysterectomy...Women who have completed childbearing, in whom medical therapy has failed, or who have contra-indications to medical therapy are candidates for hysterectomy without cervical preservation." 

There is no evidence in the medical record that the patient has undergone medical therapy. Therefore, the treatment of laparoscopic hysterectomy is not medically necessary and not within the standard of care. 

The patient states that she desires hysterectomy because has a history of pelvic pain, prefers to not have a diagnostic laparoscopy as she does not want two surgical procedures, and her family history includes women who have undergone hysterectomy. There is no evidence in the medical literature to support hysterectomy procedures due to a family history of hysterectomy procedures. The patient has not undergone a complete evaluation for pelvic pain, which includes a laparoscopy which has not been performed. Performing hysterectomy for undiagnosed pelvic pain is not within the standard of care. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 
The standard of care was applied to the determination.