Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Family history of ovarian cancer
Treatment: Hysterectomy
The insurer denied: Hysterectomy
The denial is upheld.

This patient is an adult female G2P2 (Gravida two Para two) with a family history of ovarian cancer in her mother. She had a workup including an ultrasound which revealed a thickened endometrium. She underwent a hysteroscopy D&C (Dilation and Curettage) last year which revealed a polyp and atrophic endometrium. The request is for a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. 

The proposed treatment of a hysterectomy is not considered medically necessary. 

According to Muto, risk-reducing bilateral salpingo-oophorectomy (rrBSO) is reserved for women at the highest risk of epithelial ovarian and fallopian tubal cancer. The lifetime risk of ovarian cancer is 35 to 46 percent in women with BRCA1 (BReast CAncer gene one) gene mutations, 13 to 23 percent in those with BRCA2 ((BReast CAncer gene two) mutations, and 3 to 14 percent in those with Lynch syndrome (hereditary nonpolyposis colorectal cancer syndrome). In the general population, the lifetime risk is 1.5 percent. Women at average risk or who have isolated risk factors for ovarian cancer are not candidates for rrBSO. 
Risk-reducing bilateral salpingo-oophorectomy (rrBSO) is the most effective approach to reducing the risk of ovarian and fallopian tubal cancer in high-risk women. The procedure also decreases the risk of breast cancer in women with BRCA (breast cancer gene) mutations. This effect has been best studied in women with BRCA mutations. Accumulating data support the efficacy of rrBSO in significantly reducing the risk of both gynecologic cancers (ovary, fallopian tube, peritoneum) and breast cancer in women who carry BRCA1 or BRCA2 mutations. As an example, in one study the relative risk of ovarian/fallopian tubal/peritoneal cancer after rrBSO was 0.04 (95% CI 0.01-0.16), and in another study the relative risk of breast/ovarian/fallopian tubal/peritoneal cancer was 0.25 (95% CI 0.08-0.74). 
A routine hysterectomy at the time of BSO (Bilateral Salpingo Oophorectomy) is not indicated unless other indications for this procedure exist. Moreover, there are no national guidelines that recommend routine hysterectomy in BRCA mutation carriers. There has been considerable debate about whether mutation carriers should undergo hysterectomy at the time of BSO. Few high-quality data exist, but the limited information suggests there is no increased risk of endometrial cancers. For example, one study that included over 3000 women with a BRCA mutation found only 17 uterine cancers, and most were attributable to Tamoxifen use in whom the ten-year absolute risk was 2.8 percent. While this and other studies have also reported a possible small excess risk of uterine cancers in mutation carriers, the absolute risk is low, and it is not clear that the benefits associated with hysterectomy are sufficiently large enough to warrant the risks associated with surgery. 
In review of the medical record, the patient's mother had ovarian cancer. There is no evidence that the patient underwent genetic counseling to determine her risk for a familial syndrome. Furthermore, there is not any data that supports the recommendation for a hysterectomy as part of this risk reducing procedure. Although suspected there is no documentation of a genetic base for her mother's cancers so prophylactic surgical intervention is not indicated at this time. Therefore, a hysterectomy with BSO does not meet the standard of medical practice at this time and is not medically necessary.