Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premenstrual syndrome (PMS) / premenstrual dysphoric disorder (PMDD).
Treatment:  Hysterectomy (procedure code 58571).

The insurer denied coverage for hysterectomy (procedure code 58571).  The denial is upheld

The patient is a female with a diagnosis of premenstrual syndrome (PMS) / premenstrual dysphoric disorder (PMDD) with complaints of severe anxiety and panic attacks that start about a week before menses and last until 2 days after menses. The patient was placed on oral contraceptives but states she cannot tolerate getting her menses, as it causes her significant anxiety and distress. The patient was offered Fluoxetine and has not taken it due to fear of change. She underwent a hysterectomy with bilateral salpingectomy.

The insurer has denied coverage for a hysterectomy (procedure code 58571) as not medically necessary. In their Final Adverse Determination letter they write that the patient does not meet the criteria for a hysterectomy because she has not tried and failed recommended conservative therapies.

In an appeal letter her doctor writes that the patient has a history of severe premenstrual dysphoric disorder, severe anxiety associated with menses affecting her ability to function despite hormonal therapy, and continued heavy bleeding with severe anemia, with a hematocrit in the mid 20's. The patient is certain she never wants to have children and has no sexual desire or interest. The patient has been evaluated by psychology regarding her severe, debilitating anxiety attacks, and the psychologist concurs with a hysterectomy addressing her significant psychological issues, which are debilitating. 

A clear diagnosis of PMS or PMDD should be established before treatment is considered. In particular, women must be symptom-free during the follicular phase. Selective serotonin reuptake inhibitors (SSRIs) is recommended as the first-line options for women with moderate to severe premenstrual symptoms, especially for those who experience depressive and anxious symptoms. SSRIs can be administered as a continuous daily therapy, luteal phase-only treatment (starting on cycle day 14), or symptom-onset therapy. Many women prefer to try a combined estrogen-progestin oral contraceptive (COC) rather than an SSRI as first-line therapy. Typically, COC containing drospirenone with a four-day pill-free interval.  If symptom relief with a monophasic COC with a shortened pill-free interval is inadequate, an SSRI can be added. Amelioration of depressive and anxious symptoms may be inadequate with COC-only treatment.

For women who have not responded to or cannot tolerate SSRIs or COCs and continue to experience severe symptoms, a trial of gonadotropin-releasing hormone (GnRH) agonist therapy with estrogen-progestin add-back is recommended. Medical therapy of PMDD is usually successful. As a result, surgery is considered only as a last resort (e.g., in cases with severe, disabling symptoms that have responded to GnRH agonist and hormone add-back therapy for at least six months). Note that the recommended surgery is a bilateral oophorectomy and not a hysterectomy. The ovaries produce the hormones responsible for this patient's symptoms. Removing the uterus and tubes will not affect or cure this patient's PMDD. It is unclear why a hysterectomy was performed. A hysterectomy is not indicated and was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for hysterectomy (procedure code 58571) is upheld. Medical Necessity is not substantiated.