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

The enrollee is requesting authorization and coverage for uterine fibroid removal surgery. Her back pain radiates to her leg and she has been treated with pain medications. On examination, she had a painful and reduced range of motion of the lumbosacral spine with an antalgic gait. A physical therapy consult diagnosed her with lumbar sprain/strain. A home exercise program was given. At a gynecology visit for abnormal vaginal bleeding, the treatment plan was for laboratory work and an endometrial biopsy. A pelvic ultrasound showed an enlarged uterus with a mass at the uterine fundus, consistent with a uterine fibroid, and a right ovarian cyst. She was started on Provera. The enrollee had a telephone consult with a different OB/GYN as she felt her concerns were not being addressed. She indicated she was interested in surgery for fibroid removal. Hysterectomy versus myomectomy was discussed. Later the enrollee returned to the OB/GYN who performed the biopsy and indicated her bleeding had not improved with the Provera. The plan was to consider uterine artery embolization versus hysterectomy, with a recommendation against myomectomy. She was subsequently evaluated by urogynecology for stress incontinence and was given the options of biofeedback or a surgical procedure. Review of the record indicates this enrollee has had back pain for three years.  She also has stress incontinence and has to wear a pad daily.  The enrollee thought the pain was related to a fibroid and wanted it removed.  The provider attempted to explain to the enrollee that, though the fibroid could be causing her back pain, there is no guarantee it would be relieved after surgery, because there could be another cause. The medical literature describes fibroids as benign tumors that originate from the uterine smooth muscle. The most common symptom is abnormal uterine bleeding and usually excessive menstrual bleeding. Other symptoms can include urinary frequency and urgency, urinary retention and low back pain. The authors indicate management should be tailored to the size and location of fibroids, the enrollees age, symptoms, and desire to preserve fertility. They describe myomectomy as the preferred surgical procedure for women with submucosal fibroids who wish to preserve their uterus or fertility. It is optimal for submucosal fibroids of less than three centimeters when more than 50% of the tumor is intracavitary.  The risk for recurrence must be balanced against the potential benefits of uterine-sparing procedures.   The enrollee has a fibroid that is 8.3 centimeters at the fundus. The record does not support the fibroid is submucosal and that more than 50% of the tumor is intracavitary. Literature indicates this type of surgery is optimal for enrollees with a less than three-centimeter fibroid. Further, based on review of the enrollees history, there is insufficient evidence the bleeding is caused by fibroids. The enrollee has multiple complaints and evidence in the record does not support this surgery as the best option to address them.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.