Ovarian Cyst: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biopsy of a right ovarian cyst and a hysterosalpingogram. The submitted documentation supports the medical necessity of a portion of the requested services. Ovarian cysts noted on ultrasound are typically followed with repeat scanning in six to eight weeks to monitor for resolution. In this case, the patient underwent a pelvic ultrasound that showed a small ovarian cyst that is consistent with a hemorrhagic cyst. There are no unique clinical circumstances noted in the submitted records that would support ovarian cyst biopsy, as this is not consistent with evidence-based standard of care. Therefore, the requested biopsy of the right ovarian cyst is not medically necessary to treat the patient’s medical condition.There is sufficient support for the requested hysterosalpingogram.

A 54-year-old female enrollee has requested right ovary removal (oophorectomy) for treatment of her ovarian cyst. Findings: The physician reviewer found that decisions regarding management of an ovarian cyst are made based on a combination of factors including the patient’s symptoms, age and menopausal status. Also considered are a patient’s personal and family history of ovarian or related cancers, findings on pelvic and ultrasound examination, and laboratory results. The primary issues are risk of malignancy or rupture, risk of torsion, and severity and persistence of pain. Management of the post-menopausal patient tends to be more aggressive since the risk of malignancy tends to be elevated. Despite these efforts, the data may still be insufficient to determine the etiology of an ovarian cyst.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for immediate surgery to remove a left ovarian cyst. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity of the requested procedure in this clinical setting. This patient describes pain over the last year, and a cyst that has decreased in size. These symptoms are more consistent with a functional ovarian cyst, which arises from the normal functioning of ovaries, as opposed to a pathologic cyst, such as a chocolate cyst. Pathologic cysts are often related to endometriosis and do not get smaller. The patient's provider noted an interval decrease in the size of the lesion. In a review on adnexal/ovarian masses, A study noted “A cyst may also become hemorrhagic without rupture.

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for laparoscopic total hysterectomy for treatment of the enrollee’s uterine fibroids, ovarian cyst and pelvic pain syndrome. Findings: The physician reviewer found that Uterine fibroids are the most common solid pelvic tumors in women and the leading indication for hysterectomy. The two most common symptoms for which women seek treatment for this diagnosis are abnormal bleeding and pelvic pressure. Symptoms and treatment options are affected by the size, number, and location of the leiomyomas. Furthermore, acute pelvic pain is a common presenting complaint in women. The differential diagnosis includes gynecologic, urologic, musculoskeletal, gastrointestinal, vascular and metabolic disorders. A thorough history and physical examination is necessary to narrow the possible diagnoses and focus the work-up.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for ovarian cyst was denied, the published record says the denial is worth fighting.