Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic pain, severe dyspareunia and dysmenorrhea.
Treatment: Laparoscopic Uterine Nerve Ablation (58578).
The insurer denied the Laparoscopic Uterine Nerve Ablation (58578).
The denial is upheld.

The patient is a female G0 (no pregnancies). She presented to a gynecologist with a history of pelvic pain, severe dyspareunia and dysmenorrhea. Her pelvic examination revealed nodularity of the uterosacral ligaments. Endometriosis was suspected. A pelvic ultrasound revealed a 1.5 cm (centimeter) mass adjacent to the cervix on the right. Operative laparoscopy and placement of a levonorgestrel IUD (intrauterine device) was planned and performed. A right cul de sac endometriosis implant nodule was seen. The nodule was resected and a bilateral uterosacral nerve ablation was performed with the harmonic scalpel.

No, the Laparoscopic Uterine Nerve Ablation (58578) was not medically necessary.
Endometriosis is one of the most common gynecologic disorders and is found in 70% to 90% of patients with pelvic pain symptoms. Women with endometriosis have an increased risk of abdominopelvic pain, dysmenorrhea, and dyspareunia compared with controls without endometriosis. The evaluation of pain from endometriosis and its response to treatment are made difficult by methodologic difficulties in measuring pain; incomplete understanding of the mechanism by which endometriosis causes pain; difficulty in determining the success of medical and surgical therapies compared with placebo; the tendency for chronic pain to progressively involve surrounding organ systems beyond the reproductive tract; and pain attributed to endometriosis when other coexisting conditions may be the true cause of pain.

Laparoscopic treatment of endometriosis does lead to improvement in disease and pain and thus supports the recommendation to treat endometriotic lesions at the time of diagnostic laparoscopy. Surgical options for the treatment of endometriosis include the use of unipolar or bipolar cautery, laser ablation using potassium-titanyl-phosphate, carbon dioxide, or neodymium: yittrium, aluminum, garnet lasers, and excision techniques. Each has advantages and disadvantages with respect to lesion removal, tissue trauma, and bleeding.

Laparoscopic uterosacral nerve ablation is a technique designed to disrupt the efferent nerve fibers in the uterosacral ligaments to decrease uterine pain for women with intractable dysmenorrhea. However, a large randomized, controlled trial comparing results of conservative laparoscopic surgery for endometriosis with conservative surgery with laparoscopic uterosacral nerve ablation observed no difference between groups in the proportions of patients having recurrent dysmenorrhea 1 and 3 years after surgery.

The American Society for Reproductive Medicine, in its Practice Committee Opinion, states: "Currently, laparoscopic uterosacral nerve ablation does not appear to offer any added benefits beyond those that can be achieved with conservative surgery for endometriosis alone. Although laparoscopic uterosacral nerve ablation has a low risk of complications, uterine prolapse and transection of the ureter have been reported."

The American College of Obstetrics and Gynecology, states: "Several randomized trials have demonstrated the lack of efficacy of uterosacral nerve ablation as an adjunct to surgical management of endometriosis."

Therefore, given the above, the procedure is not within the standard of care and is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient
The American Society for Reproductive Medicine, in its Practice Committee Opinion, states: "Currently, laparoscopic uterosacral nerve ablation does not appear to offer any added benefits beyond those that can be achieved with conservative surgery for endometriosis alone. Although laparoscopic uterosacral nerve ablation has a low risk of complications, uterine prolapse and transection of the ureter have been reported."

The American College of Obstetrics and Gynecology, states: "Several randomized trials have demonstrated the lack of efficacy of uterosacral nerve ablation as an adjunct to surgical management of endometriosis."

Therefore, given the above, the procedure is not within the standard of care and is not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.