Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine Fibroid.

Treatment: Code 73243 (vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intra-procedural road-mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and the associated codes).

The insurer denied the code 73243 (vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intra-procedural road-mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and the associated codes). 

The denial was overturned. 

This is a female patient with a history of fibroids, abnormal uterine bleeding and menorrhagia. According to the CytoComplete Pap and/or human papillomavirus (HPV) results were the patient was negative for intraepithelial lesion or malignancy and HPV mRNA was not detected. An endometrial biopsy was done that showed minute strips of benign endometrial lining and fragments of benign endocervix. It was noted that the endometrium was not well represented. A magnetic resonance imaging (MRI) of the pelvis showed a 10 cm upper body intramural fibroid with marked mass effect upon the underlying endometrium and non-enhancing hemorrhagic appearing material in the endometrial cavity. The patient underwent uterine artery embolization. 

Uterine artery embolization (UAE) is a minimally invasive treatment for uterine leiomyomas (fibroids). The procedure is a percutaneous angiographic procedure performed with video fluoroscopic imaging with injection of embolic agents into the uterine artery. Ideal candidates for UAE include women with heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids, who are premenopausal, and who have no desire for future pregnancy. The first-line imaging study to evaluate for uterine fibroids is pelvic ultrasound. Many protocols include magnetic resonance imaging before UAE in order to properly determine the size and location and to ensure that the uterine masses are consistent with uterine fibroids. 

This patient had menorrhagia due to uterine fibroids as demonstrated by an MRI. She is premenopausal and is not interested in having children. Her Pap smear was normal. She had an endometrial biopsy that did not show any pathology. There is no contraindication in performing the uterine artery embolization and the procedure was indicated and medically necessary. 

Code 73243 (vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intra-procedural road-mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and the associated codes), considered medically necessary for this patient. 

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient. 

Based on the above, the medical necessity for code 73243 (vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intra-procedural road-mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and the associated codes),is substantiated. The insurer's denial is overturned.