Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multifibroid uterus
Treatment: Ambulatory surgery - radiofrequency ablation [0404T x (times) 1]
The insurer denied the Ambulatory surgery - radiofrequency ablation [0404Tx1].
The denial is overturned.

The patient is a gravida nine, para six (G9P6036) female with heavy menstrual bleeding. She has had this for several years and now worsening. Associated symptoms include pelvic pressure and fatigue, as well as anemia requiring iron infusions in the past. Past obstetrical history is significant for one cesarean section followed by five vaginal deliveries. Past medical history is significant for hypothyroidism and morbid obesity with a body mass index (BMI) greater than (>) 40. Past surgical history is significant for abdominoplasty and gastric bypass.

Diagnostic studies revealed a complete blood count (CBC) showing no current anemia, gynecological pelvic ultrasound showing a single 3.88 by 4.48 by 4.32 centimeter submucosal myoma, and an operative hysteroscopy was performed revealing an anterior submucous myoma with five percent protrusion into the uterine cavity along with two small endometrial polyps. Tissue sampling via an endometrial biopsy showed no hyperplasia or carcinoma of the endometrium. 

The patient was offered various treatment options and due to her desire for uterus conservation, she and her provider decided upon transcervical radiofrequency ablation. The current record does not contain information on prior therapies or evaluations.

Yes, the health plan should cover the proposed treatment.

Transcervical radiofrequency ablation has been Food and Drug Administration (FDA) approved for the treatment of symptomatic uterine leiomyomas. Transcervical (Sonata) systems have shown significant symptoms improvement and low reintervention rate via several studies. The patient's symptoms, findings, and comorbidities would benefit from this procedure.

As per the American College of Obstetrics and Gynecology (ACOG) Practice Bulletin Number 228 on Management of Symptomatic Uterine Leiomyomas, both medical and surgical management options need to be discussed with patient and selection of treatment is based on treatment goals, safety, long term goals.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

Medical treatments available are mostly hormonal and the patient's co-morbidities put her at higher risk of adverse effects. Also, some of these are short term bridges to surgery anyways. That said, a progestin intrauterine device (IUD) such as Mirena IUD (intrauterine device) is a reasonable option if the patient desired a trial.


The patient requested uterine-sparing treatments. The following are some known options:

1) Myomectomy would incur all risks associated with major surgery including general anesthesia, higher blood loss, longer post surgical recovery, longer hospital stay, and subsequent uterine adhesion formation. 2) Uterine artery embolization is a good option but there is some data showing some higher rates of reintervention. 3) Magnetic resonance-guided focused ultrasound is an emerging treatment but data is very limited.

The proposed treatment via transcervical radiofrequency ablation would benefit this patient in the following manner:

1) Her morbid obesity and multiple prior abdominal surgeries puts her at higher morbidity and mortality for general anesthesia, open or laparoscopic surgeries due to more surgical risks and adhesions, more blood loss, longer recovery, and longer hospital stay. 2) She has one submucosal myoma of a size (four to five centimeters) that would be ideal for the proposed treatment. Hysteroscopic myomectomy in this scenario would likely necessitate multiple procedures due to its large size and only five percent endometrial cavity penetration. Laparoscopic radiofrequency ablation would require general anesthesia and abdominal incisions and entry, thus higher risk than transcervical approach.