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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hysterectomy (CPT Code 58550). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients chronic uterine pain. The submitted documentation does not support the medical necessity of the requested services. In this patients case, an appropriate gynecologic workup was required due to the patients history chronic pelvic/abdominal pain. This patient did not appear to have a complete gynecologic workup for the etiology of the symptoms presented by the gynecologist nor did the records indicate that there were any consultations for the etiology of the patients pain from the primary care provider or a provider with sub-specialty certification in gastroenterology, general surgery, or urology. Chronic pelvic pain is typically difficult to treat, as the disease process is multifactorial without one specific etiology, and clinically can present in different ways and can change over time. A specific diagnosis is not found in the majority of cases. Some common diagnoses included endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. Multiple organ system, issues can present as chronic pelvic pain. Given the multifactorial nature of chronic pelvic pain, it is not unusual to have many specialties involved in the workup. From the gynecologic perspective, the workup usually entails the patients history and physical examination with laboratory testing, pelvic ultrasound, radiologic imaging, laparoscopy, and a consultation if needed to rule out non-gynecologic etiologies. Once a gynecologic workup is complete, there are two approaches depending on the results. These approaches include medical management or surgical management. A medical management approach man involve  hormones, hormone replacement therapy, analgesics narcotics, nonsteroidal anti-inflammatory drugs, psychotherapy, physical therapy,  and the treatment modalities available at pain management clinics. A surgical management approach may include surgical ligation of pelvic nerves by presacral neurectomy, or hysterectomy with or without bilateral salpingo-oophorectomy. Hysterectomy may alleviate chronic pelvic pain, especially when it is due to uterine disorders such as adenomyosis or fibroids.  In this case, however, there is no notation that fibroids were seen, nor changes suggestive of getting magnetic resonance imaging of the uterus to evaluate for adenomyosis. However, pain can persist even after hysterectomy, particularly in younger women (those less than 30) and in women with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction. Surgery to cut some of the nerves in the pelvis (presacral neurectomy) has also been studied as a treatment for chronic pelvic pain. However, this approach has shown effective predominately for endometriosis pain and has additional surgical risks, and therefore, it is not recommended for the majority of women. In this case, the patient does not appear to have had an appropriate consultation to exclude non-gynecologic etiologies of chronic uterine pain and management of the case appears to have jumped directly to a request for authorization for definitive surgical treatment based on what appears to be non-emergent findings. This precluded the chance to evaluate conservative medical management options. There is no documentation that any medical management was offered and had previously failed and no documentation that a complete gynecologic workup has been done. Therefore, hysterectomy (CPT Code 58550) is not medically necessary for the treatment of this patient.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.