Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Painful menses
Treatment: Surgery - Hysterectomy (Code: 58571)
The insurer denied: Surgery - Hysterectomy (Code: 58571)
The denial is overturned.

The patient is an adult female, gravida 2, para 2 (G2P2), with history of heavy painful menses. She had tried oral contraceptive pills (OCPs), progestin only pills, and intrauterine device (IUD) for medical management without relief. She had a uterine polyp removal. She had a workup with normal endometrial biopsy, normal pap, and an ultrasound revealing a small fibroid. She underwent a robotic hysterectomy last month. This has been denied as not medically necessary. This is being appealed.

The requested health service is medically necessary.

According to the American College of Obstetrics and Gynecology (ACOG), the most common causes of abnormal uterine bleeding (AUB) include uterine pathologies (PALM-COEIN (PALM: polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia. COEIN:  coagulopathy, ovulatory dysfunction, endometrial, iatrogenic), classifications are shown parenthetically), such as endometrial polyps (AUB-P), adenomyosis (AUB-A), uterine leiomyomas (AUB-L), and endometrial hyperplasia or carcinoma (AUB-M). Other possible etiologies include systemic conditions, such as coagulopathies, both inherited (e.g., von Willebrand disease) and acquired (AUB-C), and ovulatory dysfunction (AUB-O). Ovulatory abnormal uterine bleeding is more common than abnormal uterine bleeding that is related to ovulatory dysfunction. 
The American College of Obstetrics and Gynecology (ACOG) states that medical therapy should be considered before surgical therapy. They also state that:
1) The levonorgestrel intrauterine device (IUD) has been shown to be effective in treating abnormal uterine bleeding and should be considered for all age groups.
2) Medical treatment options for abnormal uterine bleeding include progestin therapy and combined hormonal contraception.
3) Women who have completed childbearing, in whom medical therapy has failed, or who have contra-indications to medical therapy are candidates for hysterectomy without cervical 
preservation.
4) Because ovulatory dysfunction (AUB-O) is an endocrinologic abnormality, the underlying disorder should be treated medically rather than surgically. Surgical therapy is rarely indicated for the treatment of ovulatory dysfunction (AUB-O), unless medical therapy fails, is contraindicated, is not tolerated by the patient, or the patient has concomitant significant intracavitary lesions.
5) Failure of medical management requires further investigation, including imaging or hysteroscopy.
6) The choice of treatment of ovulatory dysfunction (AUB-O) is guided by the goals of therapy, which may be to stop acute bleeding, avoid future irregular or heavy bleeding, simultaneously 
provide contraception, and prevent complications, such as anemia, unnecessary surgical intervention, and diminished quality of life.
7) Endometrial ablation is not recommended as a first-line therapy for ovulatory dysfunction (AUB-O). Physicians must provide thorough informed consent and adequate counseling to 
women with ovulatory dysfunction (AUB-O) who desire endometrial ablation.
The patient had persistent severe abnormal uterine bleeding despite multiple medical management attempts. She had tried the levonorgestrel containing intrauterine device (IUD), oral contraceptives, progestins, and has had a less invasive surgery with polyp removal. She has had a normal pap and endometrial biopsy. She also has a fibroid uterus. Because she failed medical management and had a thorough workup the definitive surgery with a hysterectomy meets the literature recommendations. This is the standard of medical practice, appropriate for the diagnosis, and not for convenience. Therefore, this meets the definition of medical necessity.