Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Abnormal uterine bleeding (AUB).
Treatment: Outpatient procedure 0404T, ablation of uterine fibroids.
The insurer denied coverage for outpatient procedure 0404T, ablation of uterine fibroids.
The denial is overturned.

This is a female with a history of abnormal uterine bleeding. She had a 3 centimeter (cm) submucosal fibroid and an endometrial polyp. She has had menorrhagia for the past two years with intermenstrual spotting. She had been on Aygestin for three weeks. An office hysteroscopy and endometrial biopsy was scheduled at that time. A submucosal fibroid was seen in the left lateral uterine wall. The endometrial biopsy was benign. A plan was made to perform a radiofrequency ablation (RFA) of the fibroids to assist with uterine bleeding.

Per the American College of Obstetricians and Gynecologists (ACOG) (2012 Reaffirmed 2021), "Menstrual flow outside of normal volume, duration, regularity, or frequency is considered abnormal uterine bleeding (AUB). One third of outpatient visits to the gynecologist are for AUB, and it accounts for more than 70% of all gynecologic consults in the perimenopausal and postmenopausal years." Additionally, "Abnormal uterine bleeding most frequently occurs in women aged 19-39 years as a result of pregnancy, structural lesions (eg, leiomyomas or polyps), anovulatory cycles (eg, PCOS (polycystic ovarian syndrome)), use of hormonal contraception, and endometrial hyperplasia. Endometrial cancer is less common but may occur in this age group." Also, "For anatomic causes of abnormal uterine bleeding, such as uterine myomas or polyps, surgery may be indicated. Endometrial ablation and resection are minimally invasive surgical options to control bleeding in women who have completed childbearing." 

A different ACOG (2021) bulletin states, "Prolonged or heavy menstrual bleeding, with or without anemia, and the sequelae of uterine enlargement are the most common presenting symptoms of patients with uterine leiomyomas. Abnormal uterine bleeding associated with leiomyomas is referred to as (AUB-L). Pelvic pressure, urinary frequency, and constipation also can result from the presence of large leiomyomas within the pelvis and are collectively referred to as bulk symptoms." Additionally, "There are a variety of treatment options for leiomyomas, including expectant, medical, interventional, and surgical therapies. Although evidence exists regarding outcomes with specific therapies, comparative effectiveness data are lacking for leiomyoma management options. When considering treatment options, patient-specific symptoms and severity should be addressed. If a patient describes symptoms that are neither severe, nor debilitating, expectant management may be appropriate. Medical treatments primarily address bleeding symptoms. Procedural interventions and surgical approaches treat bulk symptoms by decreasing uterine mass. Although there is evidence to suggest that nonsteroidal anti-inflammatory drugs are associated with modest improvement in heavy menstrual bleeding, there is no evidence for their use specifically for the treatment of AUB-L."

A systematic review by Taheri, et al., (2019) compared studies looking at uterine volume after uterine artery embolization (UAE), focused ultrasound (FUS) and more recently, radiofrequency ablation (RFA) of fibroids. They found that, "The pooled fibroid volume reductions at six months seen with RFA were 70%, UAE 54% and FUS 32%. All three types of nonresective treatment result in fibroid volume reduction. However, fibroid volume reduction is most marked with RFA, with UAE resulting in the next most volume reduction."

The requested service is likely to be more beneficial than any of the standard treatments and/or procedures for this patient. 

The carrier's denial of outpatient procedure 0404T is overturned.