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Fibroid Removal denials: what the review data shows
Independent reviewers have decided 23 published cases where an insurer denied Fibroid Removal — and they overturned the insurer 52.2% of the time. A denial for Fibroid Removal is a starting position, not a final answer.
Published decisions
23
2001–2026
Overturned
52.2%
12 denials reversed
Conditions behind fibroid removal denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Fibroids | 11 | 45.5% |
| Uterine Fibroids | 7 | 71.4% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 13 | 53.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 9 | 44.4% |
Typical time to a decision
20 days
Most land between 14 and 21 days
Handled as urgent
26.1%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic surgical radiofrequency ablation (RFA) of uterine fibroids. Uterine fibroids are the most common benign tumors of the female reproductive tract causing symptoms such as heavy bleeding, bulk symptoms, pain, and increased urinary frequency. Some patients prefer minimally invasive approaches for fibroid treatment with desire for uterine conservation. Both uterine artery embolization and ultrasound guided radiofrequency ablation (RFA) are options for uterine-sparing minimally invasive techniques. In a recent systematic review of nonresective treatments for uterine fibroids published by Taheri and colleagues, the authors found that the pooled fibroid volume reductions at six months after RFA and uterine artery embolization were 70% and 54%, respectively.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical removal of fibroids (laparoscopic myomectomy). The records document that this patient has a history of heavy bleeding and pelvic pain in the setting of a fibroid uterus. The patient has requested treatment with a uterine sparing procedure. On review of the peer-reviewed medical literature and current guidelines, treatment with myomectomy is a reasonable option for the treatment of this patient’s pelvic pain. Per the American College of Obstetricians and Gynecologists (ACOG) recommendations, uterine fibroids are the leading indication for hysterectomy.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acessa laparoscopic radiofrequency ablation procedure. Researchers concluded that, “laparoscopic radiofrequency ablation therapy is efficacious for small-sized and non-pedunculated symptomatic uterine fibroids.” Based on this review, this patient is not a suitable candidate for the Acessa laparoscopic radiofrequency ablation procedure. The patient’s fibroid is pedunculated and measures 6.9 x 4.8 x 7.1 cm. In addition, the patient previously underwent magnetic resonance guided treatment of her myomas, and there is a lack of data demonstrating that subsequent radiofrequency in this clinical setting is safe and effective. The patient has heavy bleeding and symptoms related to her fibroid uterus. Palpation of the myoma causes pain.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Fibroid Removalwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.