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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic hysterectomy (vaginal, laparoscopically-assisted) for treatment of the enrollee, who has a history of excessive uterine bleeding and severe pelvic pain. Findings:  The physician reviewer found that the patient has a history of pelvic pain, anemia and menorrhagia. Her evaluation for these complaints included a pelvic ultrasound significant for a fibroid uterus, and normal endometrial biopsy. Her gynecologist has recommended a laparoscopic hysterectomy (vaginal, laparoscopically-assisted). The patient has a significant history of abnormally heavy bleeding and pelvic pain. 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, or adenomyosis. If anatomic abnormalities are not present, long-term hormonal treatment may be used to regulate bleeding, reduce menstrual blood loss and the dysmenorrhea that may be associated with the abnormal bleeding. For women with menorrhagia, administration of oral progestin or oral contraceptives may significantly reduce menstrual blood loss. Pain may be reduced with this treatment as well. These agents are often required to obviate the need for endometrial ablation or hysterectomy. Because of its reduced risks, medical therapy should be offered before surgical intervention unless it is otherwise contraindicated. The endometrial cavity was appropriately evaluated within the standard of care during this evaluation. According to the medical record there was no contraindication to medical therapy. The medical record documents that treatment options were discussed at a preoperative consult. Of these options, the only one documented was hysterectomy. The record submitted do not indicate that medical therapy was discussed and tried with this patient. The American College of Obstetrics and Gynecology, in its Practice Bulletin, states: Surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. Avoidance of anemia, reduction of excessively heavy bleeding, and increased, though imperfect, predictability of bleeding are appropriate goals to attempt to achieve with medical therapy. Surgical options include hysterectomy. The records, in this patients case, did not demonstrate that medical therapy was offered. As such, the requested procedure does not meet the recognized professional standards of care. Therefore, laparoscopic hysterectomy (vaginal, laparoscopically-assisted) is not medically necessary in the treatment of this patient. Final Result: The reviewer determined that the requested procedure is 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.