Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral polycystic changes
Treatment: Surgery and inpatient stay
The insurer denied the surgery and inpatient stay.  
The denial is upheld.

The Surgery and inpatient admission were not medically necessary.

The patient is a G1 P0 Ab1 female with a diagnosis of dyspareunia. She consulted her gynecologist. The patient was on depot medroxyprogesterone. The pelvic examination was normal. A pelvic ultrasound revealed bilateral polycystic changes to the ovaries with a normal uterus. The gynecologist recommended multiple options including oral contraceptives, pain medications, lifestyle modifications and "conservative." The patient declined all options and according to the medical record "insisted" on a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The procedure was performed. 
Chronic pelvic pain (CPP) is generally defined as pain present in the pelvis, more often than not, for six months or longer. It may be cyclic or continuous in nature. Pain that is present at least five days/month occurs in 12% of women of reproductive age and is the reason for hysterectomy in approximately 12% of such procedures. Approximately half of all operative laparoscopies are performed to investigate problems with pain, many of those chronic in nature. As a multifactorial disease, CPP often challenges the best of clinicians. When organic pathology is detected, its precise relationship to the production of symptoms is often uncertain. The longer the pain has gone on, the more likely treatment will be prolonged and perhaps incompletely successful. 
The few placebo-controlled trials of surgery that have been carried out have demonstrated substantial nonspecific (placebo) effects of surgery, which can occur in 65 to 100% of cases and may last as long as a year. The surgeon seeing the patient four to six weeks after surgery may witness partial or complete relief of pain, only to see it return three to 12 months later and assume this must represent a return of disease. This list of contributing factors is made on the basis of a careful and detailed clinical history. Physical examination supplies additional detail(s) and confirmation of diagnoses, but in the majority of cases, if uncertainty remains, more historical questions need to be asked. 

A very detailed history enables the physician and patient to formulate a well-designed set of interventions. Even if surgery seems needed, simultaneous treatment of other components is more likely to result in good outcome. In-office testing and diagnostic techniques as well as imaging can assist in determining the diagnosis. CPP can be associated with a wide range of conditions which could include endometriosis, chronic pelvic inflammatory disease, musculoskeletal pain, bladder pain and IBS (irritable bowel syndrome). Diagnostic laparoscopy is commonly indicated and performed for pelvic pain, to evaluate the pelvis for some of these conditions, particularly when endometriosis is suspected. 

Hysterectomy with BSO (bilateral salpingo-oophorectomy) in reproductive age patients results in surgical menopause, potentially creating a need for long term hormone replacement therapy, and must be considered as an option with caution. It is offered within the standard of care when less complicated or invasive management has failed. Thus, initial management for pelvic pain should be directed at the final diagnosis. 

The patient has a history of dyspareunia with chronic pelvic pain. Multiple treatment options were discussed at her office consultation, including medical and lifestyle management. Laparoscopy was not discussed. Hysterectomy with BSO was offered without a complete medical evaluation or a trial of less complicated or invasive management. Therefore, the treatment was not medically necessary, and the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.