Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested vaginal hysterectomy with McCall vault suspension for treatment of the enrollees pelvic pain and menorrhagia. Findings: The physician reviewer found that upon review of the clinical notes and peer-reviewed medical literature, the requested procedure is not medically indicated in this clinical setting. The patient presented with a variety of different medical issues and had several pathologic changes noted upon examination and cytology. However, none of these medical issues rise up to the level that demonstrates the medical necessity of a vaginal hysterectomy. The patient presented with menorrhagia, uterine prolapse, pelvic pain, and anemia. She also had an abnormal Papanicolaou (Pap) smear. The patient reported concerns with family history of female cancers. The management of abnormal Pap smears and algorithms for care has been defined by the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP). The patient presented with a high-grade squamous intraepithelial lesion Pap smear and an appropriate colposcopy evaluation was performed. The cervical biopsy results suggested cervical intraepithelial neoplasia (CIN) 2/3. The ACOG guideline recommendations are to proceed with excisional biopsy such as a loop electrocautery excision procedure cone or cold knife cone. If a higher degree of pathology is present, or the margins are not free of disease or if the pathology continues with follow-up testing, then a hysterectomy would be appropriate. A hysterectomy is typically not recommended in that excision itself can be curative.  If an excisional biopsy finds more significant pathology like cervical carcinoma, then consultation and management with gynecologic oncology would be appropriate. As to medical issue concerning a uterine prolapse, the management typically depends on the degree of prolapse, patient symptoms, and other comorbid factors. The degree of prolapse, in this patients case, is difficult to determine because in several office notes the subjective symptoms are not mentioned and no prolapse changes are documented on pelvic examinations. A provider note stated that the cervix has prolapsed down in the vagina but there was no stage or grade presented. The staging/grading of a prolapse would assist in identifying the type of procedure best suited to manage the patients medical condition. Furthermore, there is no documentation that this patient has tried and failed other conservative treatment options like pelvic floor training, pelvic physical therapy, biofeedback or a vaginal pessary. The patient also demonstrated a history of pelvic pain but the submitted documentation does not support a diagnosis of adenomyosis. There was no orthopedic evaluation or magnetic resonance imaging included in the documentation. The symptoms as described by the chart appear to be more related to musculoskeletal issues. As to the patients history of regular but heavy cycles, there is documentation of a normal pelvic ultrasound (possible mild arcuate uterus) and normal bimanual pelvic examination. While the OCP was reported to have been ineffective for treatment of the patients menorrhagia, the notes indicated that the patient has declined alternative options like Mirena IUD and endometrial ablation. The alternative treatment options have been known to reduce menses by 90%. Equally important to address was the patients anemia. Although hysterectomy may be the ultimate management for the increased morbidity associated with anemia, it is not typically a first line management and there were no records submitted to reflect this patients degree of anemia. The patient also mentioned a family history of female cancers but the only documentation reported is of a maternal cousin with early breast cancer. The patients concern about cancer in her family does not rise to the level of performing a hysterectomy. Therefore, for the reasons stated above, the requested vaginal hysterectomy with McCall vault suspension is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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 a similar medical condition.