Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services with a tertiary level of care physician who is dually board certified in both obstetrics and gynecology and reproductive endocrinology and infertility. Reproductive endocrinology and infertility medicine is a subspecialty of obstetrics and gynecology. As the name suggests, and according to the American Board of Obstetrics & Gynecology (ABOG), this subspecialty focuses on complex reproductive disorders. This may include the surgical management of these conditions. However, it should be noted that physicians in the field of general obstetrics and gynecology (OB/GYN) also manage a wide range of conditions on a routine basis. According to the American College of Surgeons, OB/GYNs typically evaluate infertility, abnormal uterine bleeding, leiomyomata, pelvic masses, pelvic organ prolapse, abnormal Pap smears, pelvic pain, endometriosis, breast disorders, and urinary incontinence. Examples of minor office procedures are colposcopy, endometrial biopsy, Pap smears, and vulvar biopsy. Office ultrasound is performed for both obstetrics and for gynecologic conditions. Some generalists provide considerable primary care in addition to the typical gynecologic procedures. Examples of outpatient procedures include laser surgery, diagnostic laparoscopy, operative laparoscopy such as laparoscopic ovarian cystectomy, tubal ligation, diagnostic and operative hysteroscopy, and endometrial ablation. Inpatient surgical procedures include hysterectomies performed vaginally, abdominally, and laparoscopically. Other examples of inpatient procedures include abdominal or laparoscopic myomectomies. Obstetrical procedures include cervical cerclage, dilation and curettage, amniocentesis, Cesarean section, circumcision, and forceps and vacuum deliveries.In this case, the patient has been diagnosed with a fibroid uterus. Uterine fibroids are the most common benign tumors of the reproductive tract causing symptoms such as heavy bleeding, bulk symptoms, pain, and increased urinary frequency. Some patients prefer minimally invasive approaches for fibroid treatment with desire for uterine conservation. Both uterine artery embolization and ultrasound guided radiofrequency ablation are options for uterine-sparing minimally invasive techniques. Bradley and colleagues noted that radiofrequency ablation has emerged as a safe and effective treatment option for women with symptomatic uterine fibroids and can be delivered by laparoscopic, transvaginal, or transcervical approaches. This patients records document a history of heavy menstrual bleeding and a fibroid uterus. According to email correspondence dated 1/03/22, the patient indicated that she did not wish to become pregnant. The patient also appears to have no diagnosis of a complex reproductive or infertility disorder. Rather, her interest in finding a reproductive endocrinologist was based on her history of abnormal uterine bleeding and complex history including apparent hormonal abnormalities. She had also expressed some dissatisfaction with prior treating providers. Based on the available documentation and current medical literature, the patient may be a candidate for treatment with radiofrequency ablation to treat the condition. Radiofrequency ablations are often performed by reproductive endocrinology and infertility providers that seek to perform uterine-sparing procedures that may still permit future pregnancies if so desired. In this case, however, the patient has indicated that she has no interest in pregnancy and has no apparent reproductive/infertility disorder. While ultrasound-guided radiofrequency ablation may be appropriate for this patients condition, there is no requirement that it be performed by an obstetrician/gynecologist that is further subspecialty trained as a reproductive endocrinologist/infertility specialist. In contrast, the procedure may be performed by any obstetrician/gynecologist that is trained and privileged to perform the procedure in his or her respective hospital or surgical center. As noted above, management of abnormal uterine bleeding and surgical ablative procedures are well within the scope of a general obstetrician and gynecologist, particularly in the absence of a complex reproductive or infertility disorder. Therefore, the requested services with a tertiary level of care physician who is dually board certified in both obstetrics and gynecology and reproductive endocrinology and infertility are not medically necessary in this patients case.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.