Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroids (abnormal vaginal bleeding)
Treatment: Laparoscopic hysterectomy with cystourethroscopy
The insurer denied laparoscopic hysterectomy with cystourethroscopy.
The denial is upheld.

The patient is an adult female with a history of menorrhagia and fibroids who consulted her gynecologist. An MRI (magnetic resonance imaging) revealed adenomyosis and a submucous fibroid. An endometrial biopsy revealed fragments of an endometrial polyp. Laparoscopic hysterectomy is planned. The service was denied coverage by the health plan on the basis of lack of medical necessity. The denial is being appealed.

The laparoscopic hysterectomy with cystourethroscopy is not medically necessary.

The medical records and medical literature were thoroughly reviewed. The patient had a complaint of postmenopausal bleeding. The pathophysiologic reasons for the abnormal uterine bleeding include structural causes such as endometrial polyps or fibroids and infectious causes such as chronic endometritis, as well as "idiopathic" abnormal prostaglandin metabolism, abnormalities in other cellular events, endometrial neoplasia including hyperplasia or cancer, or adenomyosis.

The American College of Obstetrics and Gynecology, in its Practice Bulletin, states: "In women aged 40 years to menopause, abnormal uterine bleeding may be due to anovulatory bleeding, which represents normal physiology in response to declining ovarian function. It also may be due to endometrial hyperplasia or carcinoma, endometrial atrophy, and leiomyomas. In a patient without enhanced risk of endometrial hyperplasia, neoplasia, or structural abnormalities, such as adolescents, a trial of therapy is appropriate. For those at increased risk, such as patients with genetic risk factors for endometrial cancer, patients older than 45 years, or patients whose prolonged anovulatory cycles are associated with unopposed estrogen, initiation of therapy is appropriate after a complete diagnostic evaluation has been completed. Persistent bleeding despite therapy requires further evaluation. An appropriate trial of therapy will depend on the cause of the abnormal bleeding, the risks and benefits of the therapy, the costs to the patient, and the patient's own desire. Many causes of abnormal bleeding are amenable to medical management with nonsteroidal anti-inflammatory drugs, progestins, combination oral contraceptives, a levonorgestrel intrauterine device, or tranexamic acid. For anatomic causes of abnormal uterine bleeding, such as uterine myomas or polyps, surgery may be indicated. The primary role of endometrial sampling in patients with AUB [abnormal uterine bleeding] is to determine whether carcinoma or premalignant lesions are present, although other pathology related to bleeding may be found. Endometrial tissue sampling should be performed in patients with AUB [abnormal uterine bleeding] who are older than 45 years as a first-line test. Endometrial sampling also should be performed in patients younger than 45 years with a history of unopposed estrogen exposure (such as seen in obesity or PCOS [polycystic ovarian syndrome]), failed medical management, and persistent AUB."

The patient in this case is at higher risk for endometrial abnormalities such as hyperplasia or carcinoma due to age and persistent AUB (abnormal uterine bleeding). Fragments of an endometrial polyp were found on endometrial biopsy. Therefore further evaluation of the endometrial cavity is indicated for an accurate diagnosis, and prior to medical or surgical intervention. Therefore the patient has not met the standard of care and the procedure is not medically necessary.