Diagnosis: ovarian suppression.

Treatment: total abdominal hysterectomy and bilateral salpingo-oophorectomy.

The insurer denied coverage for a total abdominal hysterectomy and bilateral salpingo-oophorectomy.

The denial is upheld.

This female patient has a history of invasive ductal carcinoma of the right breast.

This patient had breast cancer so ovarian suppression was medically necessary. Ovarian function can be suppressed with gonadotropin releasing hormone (GnRH) agonists or by permanent methods, such as oophorectomy. In other words, the oophorectomy was medically necessary for this patient. However, it is unclear why a hysterectomy was performed.

The reason given is that the patient needed to be shifted from Tamoxifen to Arimidex. The reason given is not supported clinically. Contrary to Tamoxifen, that could cause endometrial hyperplasia, Arimidex does not cause any uterine pathology. Actually, Arimidex (anastrozole) has been used to manage endometrial hyperplasia and fibroid uterus.

Note that there was no evidence that this patient had any genetic testing that showed that she is at an increased risk of developing ovarian cancer. In summary the hysterectomy performed was not medically necessary for this patient. The patient could have undergone a prophylactic laparoscopic salpingo-oophorectomy which is an ambulatory procedure.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the total abdominal hysterectomy and bilateral salpingo-oophorectomy is upheld. The medical necessity is not substantiated.