Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abnormal uterine bleeding, premenstrual dysphoric disorder, dysmenorrhea
Treatment: Surgery (outpatient hysterectomy)
The insurer denied the outpatient hysterectomy. 
The denial is overturned. 


The proposed treatment was medically necessary.
The patient is gender asexual with no pregnancies (G0) and who has severe anxiety, panic, premenstrual syndrome (PMS), premenstrual dysphoric disorder, dysmenorrhea,
abnormal uterine bleeding, and anemia. The patient is unable to tolerate pelvic exams. The patient is virginal. The patient underwent exam under anesthesia, pap smear, endometrial biopsy, and ultrasound evaluation. Results were normal.
The patient has been under psychological care for the anxiety and panic. This is surrounding the patient's menses and causes decline in quality of life. The patient's therapist is in agreement that a hysterectomy would alleviate the patient's mental health condition. The patient underwent a total laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy without complication.
This procedure was denied as not medically necessary. This is being appealed.

The proposed treatment was medically necessary.

In a review of the literature common indications for hysterectomy include: uterine leiomyomas, adenomyosis, idiopathic abnormal uterine bleeding, endometriosis, and uterine prolapse.

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 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 American College of Obstetrics and Gynecology (ACOG) states that hysterectomy is one of the most frequently performed surgical procedures in the United States....
Medical therapy of premenstrual dysphoric disorder (PMDD) is usually successful. As a result, surgery (bilateral oophorectomy/bilateral salpingoophorectomy [surgical menopause]) is considered only as a last resort (eg, in the very rare refractory cases with severe, disabling symptoms). Three observational studies found bilateral oophorectomy, usually with concomitant hysterectomy, to be effective for such patients.
The following guidelines should be considered before resorting to a surgical approach to treatment:
- The diagnosis of premenstrual dysphoric disorder (PMDD) must be confirmed with prospective symptom recording;
- Childbearing is complete; and
- The need for several more years of therapy is anticipated based on the woman's age.
In review of the medical record and the current literature, the request for a laparoscopic hysterectomy is medically necessary. The patient has persistent abnormal uterine bleeding causing anemia despite medical management attempts. She has been on oral contraceptives. She has had a workup with normal evaluation with ultrasound and endometrial biopsy. She has
severe anxiety surrounding her menses causing panic. She is unable to tolerate exams in the office and has severe panic around anything inside of her (IUD). She is asexual and does not desire childbearing. This is a unique clinical picture. Not only does the patient have physical symptoms with heavy bleeding leading to anemia despite oral contraceptives but she also has a psychological condition causing severe anxiety/panic surrounding her menses which is causing quality of life issues. The only option that eliminates the source of the issue is a hysterectomy.
Therefore this is medically necessary for this unique clinical situation.
The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.