Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Fibroid/ Adenomyoma. 
Treatment: Procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The insurer denied coverage for procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The denial is overturned. 

This is the case of a female patient with a history of endometriosis and uterine fibroids. A magnetic resonance imaging (MRI) was reviewed showing a 5.3 x 4.0 x 4.3 cm uterus with a possible degenerating fibroid. At that time, the Sonata radiofrequency ablation procedure versus hysteroscopic resection were discussed. Per an appeal letter, six distinct fibroids were seen, and the patient noted dysmenorrhea, pelvic pain, and irregular bleeding. The appeal letter further mentions that she has had a myomectomy and has been on birth control pills and used an intrauterine device (IUD). 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. 

Specifically, regarding radiofrequency ablation (RFA), "Laparoscopic radiofrequency (Lap-RFA) ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation and are counseled about the limited available data on reproductive outcomes. Radiofrequency ablation (RFA) can be delivered by a laparoscopic, transvaginal, or transcervical approach, using ultrasound guidance to induce coagulative necrosis in targeted uterine leiomyomas. All of the approaches are similarly effective in reducing uterine leiomyoma volume and in improving quality of life metrics, but the laparoscopic approach has been studied the most rigorously. Although RFA is a reasonable option to consider for the treatment of symptomatic uterine leiomyomas, access to this technology is currently limited." 

Per Rattray et al., "Compared to myomectomy, Lap-RFA is associated with significantly lesser intraoperative blood loss, shorter procedure and hospitalization times, lesser consumption/use of disposable and reusable surgery equipment, reduced health care resource utilization, and faster return to work through 3 months posttreatment. Direct and indirect costs of Lap-RFA and myomectomy are comparable." 

This patient a good candidate for the procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus. 

The procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus is the best available treatment for this patient at this time. 

Per medical literature, Sonata radiofrequency ablation procedure is an appropriate treatment for this patient. Per records the Sonata radiofrequency ablation procedure versus hysteroscopic resection were discussed. The Sonata radiofrequency ablation procedure was elected. Therefore, procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus is the best available treatment for this patient at this time. 

The requested procedure is likely to be more beneficial than any other existing standard health service. 

The carrier's denial of the procedure code 0404T, ablation with imaging guidance for the treatment of growths in the uterus should be overturned.