Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine fibroids.

Treatment: Laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

The insurer denied coverage for laparoscopic surgery ablation for uterine fibroids (CPT code 58674).

The denial is upheld. 

This is a female patient with a diagnosis of a uterine fibroid and menorrhagia. Ultrasound imaging confirmed a 5-6 centimeter (cm) intramural fibroid with a submucous component.  She consulted her Gynecologist.  The medical records indicated that the patient desires future fertility.  Laparoscopic radiofrequency ablation of the fibroid was chosen by the patient and Gynecologist for treatment. 

Options for minimally invasive uterus-sparing alternatives for the treatment of uterine fibroids, within the standard of care include myomectomy and uterine artery embolization.  The Acessa device is a new Food and Drug Administration (FDA) approved minimally invasive treatment for uterine fibroids that uses radiofrequency energy to destroy fibroid tissue.  The novel use of radiofrequency ablation under laparo-scopic and intra-abdominal ultrasound guidance to treat patients with symptomatic myomas was first introduced in 2002.  This has prompted the development of the proposed procedure device (Acessa) which carries out laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation of uterine myomas in symptomatic women.  The key feature to using laparoscopic ultrasound lies in the inherent and immediate proximity of the transducer to the target (fibroid), allowing the use of higher frequencies with significantly increased resolution.  In addition, the versatility and mobility of laparoscopic ultrasound permits direct imaging from multiple directions and angles. 

Based on a recent study, radiofrequency volumetric thermal ablation (RFVTA) of uterine myomas safely achieved a high rate of patient satisfaction, a low re-intervention rate, and significant improvements in menstrual blood loss, symptom severity, and quality of life through 12 months of follow-up. A prospective follow-up of patients for 36 months after treatment in a multicenter international trial of outpatient, laparoscopic ultrasound-guided RFVTA of symptomatic uterine myomas has been published.  One hundred thirty-five premenopausal women with symptomatic uterine myomas and objectively confirmed heavy menstrual bleeding from uterine myomas resulted in sustained relief from myoma symptoms and continued improvement in health-related quality of life through 36 months after ablation (Berman et al).

 A recent, small randomized study comparing RFVTA with laparoscopic myomectomy reported that RFVTA resulted in shorter hospital stay and lower blood loss (Brucker et al).

The current surgical treatment, within the standard of care, for patients desiring future fertility is myomectomy.  Therefore the scientific evidence in the peer-reviewed literature does not support a result of improvement in health outcome for the proposed procedure.  Laparoscopic surgery ablation for uterine fibroids (CPT code 58674) is not the best available treatment for this patient at this time.  This patient is not a good candidate for laparoscopic surgery ablation for uterine fibroids (CPT code 58674).  The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for laparoscopic surgery ablation for uterine fibroids (CPT code 58674) should be upheld.