Gynecologic procedures: 50% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Overturned 2025 · Urgent care · age 51–64 Other · Kidney and urinary Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for urgent care services. Postmenopausal bleeding requires prompt evaluation to exclude endometrial cancer. The diagnostic algorithm begins with transvaginal ultrasonography…

   Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for urgent care services. Postmenopausal bleeding requires prompt evaluation to exclude endometrial cancer. The diagnostic algorithm begins with transvaginal ultrasonography (TVUS) to assess endometrial thickness, where a threshold ≤4 mm has a >99% negative predictive value for malignancy. If TVUS is inconclusive or endometrial thickness exceeds 4 mm, endometrial biopsy is the first-line histological assessment. Hysteroscopy with dilation and curettage is indicated when biopsy is nondiagnostic, bleeding persists, or focal lesions are suspected. Hysteroscopy allows direct visualization and targeted sampling, improving diagnostic accuracy compared to blind sampling. Endometrial hyperplasia requires tailored management to mitigate cancer risk. Atypical hyperplasia necessitates total hysterectomy due to a significant concurrent cancer risk. Diagnosis relies on histologic evaluation via endometrial biopsy or hysteroscopy-guided sampling. Delayed intervention in atypical cases correlates with progression to adenocarcinoma, underscoring the importance of timely histologic classification and risk-stratified management. Endometrial cancer surgical management prioritizes comprehensive staging and tumor removal, with total hysterectomy and bilateral salpingo-oophorectomy with lymph node assessment via sentinel lymph node mapping or systematic dissection as the cornerstone procedure. Delays in diagnosis and treatment may worsen outcomes. This patient presented with postmenopausal bleeding and had a 12 mm endometrial stripe on TVUS. The patient had an inconclusive endometrial biopsy, and a hysteroscopy with dilation and curettage was needed to diagnose the patient with endometrial hyperplasia. Given these findings, the patient did receive urgent care services, defined as services to prevent serious deterioration of the patient's health resulting from unforeseen illness or injury for which treatment cannot be reasonably delayed until the patient returns to the plan’s service area. Final Result: The reviewer determined that the services at issue were urgent care services as defined by California law. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in gynecologic oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s 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.

   Case UR25-44455

2. Overturned 2025 · Medical necessity · age 41–50 Laparoscopy · Kidney and urinary The physician reviewer found that a patient has requested authorization and coverage for either or both of the components of the requested deep excisional laparoscopic procedure: laparoscopy to oviduct/ovary with lysis of adhesions and/or laparoscopic…

   The physician reviewer found that a patient has requested authorization and coverage for either or both of the components of the requested deep excisional laparoscopic procedure: laparoscopy to oviduct/ovary with lysis of adhesions and/or laparoscopic appendectomy. Endometriosis is a condition where endometrial-like tissue is present on organs outside of the uterus and can cause symptoms including pelvic pain, heavy bleeding, dysmenorrhea, and bowel and bladder complications. The laparoscopic excision of endometriosis lesions is an established, effective method for treating endometriosis. In this case, the patient has a history of symptomatic endometriosis with symptoms persisting despite hormonal contraceptives, acupuncture, lifestyle modifications, and dietary restrictions. The literature supports the use of laparoscopy in this clinical scenario. All told, both of the components of the requested deep excisional laparoscopic procedure: laparoscopy to oviduct/ovary with lysis of adhesions and laparoscopic appendectomy are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certifications in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-46321

3. Upheld 2025 · Medical necessity · age 41–50 Infertility tx · Kidney and urinary The physician reviewer found that a patient has requested authorization and coverage for procedures related to infertility treatment and treatment related to fertility, a hysterosalpingography and radiological interpretation of hysterosalpingography…

   The physician reviewer found that a patient has requested authorization and coverage for procedures related to infertility treatment and treatment related to fertility, a hysterosalpingography and radiological interpretation of hysterosalpingography. According to scientific literature, even with the help of assisted reproductive technology, the odds of conception and live birth for those in the patient’s age group are much less than five percent. In this case, there is a lack of evidence of a disease or illness causing the patient’s difficulty getting pregnant at this point other than a normal physiological decrease in fertility. Additionally, the patient’s operative report does not mention that tubal ligation was performed. Given these findings, the requested procedures related to infertility treatment and treatment related to fertility, a hysterosalpingography and radiological interpretation of hysterosalpingography are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-46014

4. Upheld 2025 · Medical necessity · age 31–40 Infertility tx · Kidney and urinary The physician reviewer found that a patient has requested authorization and coverage for oocyte cryopreservation, including reproductive endocrinology visits; ovarian stimulation medications (gonadotropins), gonadotropin-releasing hormone (GnRH)…

   The physician reviewer found that a patient has requested authorization and coverage for oocyte cryopreservation, including reproductive endocrinology visits; ovarian stimulation medications (gonadotropins), gonadotropin-releasing hormone (GnRH) antagonist/agonist, ovulation trigger [human chorionic gonadotropin (hCG) or GnRH-analogue]; monitoring labs and ultrasounds; transvaginal oocyte retrieval with anesthesia; embryology services (oocyte identification vitrification/cryopreservation); initial storage (12 months); related laboratory fees and infection screening. There is a lack of scientific data showing that certain medications cause iatrogenic infertility and that other medications affects fertility in men or women without diabetes. Per the medical records, the patient has diagnoses of immunoglobulin A (IgA) nephropathy and chronic kidney disease. The patient does not have a diagnosis of infertility and is not undergoing any treatment that will lead to ovarian failure or cause iatrogenic infertility, such as chemotherapy, radiation therapy, or surgery to remove her ovaries. Therefore, oocyte cryopreservation, including reproductive endocrinology visits; ovarian stimulation medications (gonadotropins), GnRH antagonist/agonist, ovulation trigger (hCG or GnRH-analogue); monitoring labs and ultrasounds; transvaginal oocyte retrieval with anesthesia; embryology services (oocyte identification vitrification/cryopreservation); initial storage (12 months); related laboratory fees and infection screening are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-45991

5. Upheld 2025 · Medical necessity · age 31–40 Other · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for removal of the right ovarian cyst. According to the records, the patient has a right ovarian cyst with a low suspicion for…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for removal of the right ovarian cyst. According to the records, the patient has a right ovarian cyst with a low suspicion for malignancy. The records show that the patient does not have bowel obstruction or adnexal torsion. Given these findings, the patient’s clinical presentation does not represent an emergency. The patient’s hemoglobin A1c is high at 12.2% and estimated average glucose level is high at 303 mg/dL. Poorly controlled blood sugar before surgery significantly increases the risk of complications, including infection and poor wound healing. To mitigate these risks, it is crucial to get blood sugar levels under control before a surgical procedure. Given the patient’s most recent status, there is a lack of support in the literature for the requested procedure. All told, the requested removal of the right ovarian cyst is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-45914

6. Overturned 2025 · Medical necessity · age 31–40 Infertility tx · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for infertility services, including assisted reproductive procedures. The patient has previously undergone in vitro fertilization…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for infertility services, including assisted reproductive procedures. The patient has previously undergone in vitro fertilization and has existing viable embryos available for transfer. The goal of fertility treatment is to achieve a successful pregnancy, and in this case, proceeding with embryo transfer is the appropriate next step. Additional services related to further embryo creation or advanced laboratory procedures are not indicated when viable embryos are already available. Therefore, embryo transfer and associated preparatory services are medically necessary, while the remaining requested infertility services are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that a portion of the requested services are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications:The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45492

7. Upheld 2025 · Medical necessity · age 21–30 Uter art emboliz · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for occlusion of blood vessels in the uterus and/or magnetic resonance imaging (MRI) of the lower pelvis with and without…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for occlusion of blood vessels in the uterus and/or magnetic resonance imaging (MRI) of the lower pelvis with and without contrast.The records indicate that this patient has a diagnosis of pelvic pain. However, there is a lack of documentation that the patient has undergone a complete work-up for chronic pelvic pain. The initial work-up for a patient with chronic pelvic pain involves a detailed history, physical examination, and targeted investigations to identify potential causes and guide treatment. The assessment can include laboratory tests, imaging studies, and potentially laparoscopy. A biopsychosocial approach is essential, considering physical factors and psychological aspects that may contribute to or exacerbate a patient’s pain. In this case, there is a lack of reports that the patient has undergone a thorough work-up with laboratory tests, imaging studies, or laparoscopy to rule out common causes of pelvic pain, such as endometriosis. The provider noted concern for pelvic congestion syndrome, which may respond to treatment with medroxyprogesterone acetate, etonogestrel insert, or a gonadotropin-releasing hormone (GnRH) agonist. On review of the current medical literature, there is a lack of indication for evaluation with MRI of the lower pelvis or treatment with occlusion of blood vessels in the uterus. In addition, the requested occlusion of blood vessels in the uterus and MRI of the lower pelvis with and without contrast are not medically necessary services to protect life, to prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. Furthermore, the requested services are not medically necessary to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity. Given these findings, the requested occlusion of blood vessels in the uterus and MRI of the lower pelvis with and without contrast are not medically necessary for the evaluation and treatment of this patient’s pelvic pain. Final Result: The reviewer determined that the requested services are not medically necessary for the evaluation and treatment of the patient's medical condition. Therefore, the Health Plan's 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 patient’s 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.

   Case MN25-44986

8. Overturned 2025 · Medical necessity · age 31–40 Hysterectomy · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a hysterectomy. In this case, the record establishes that the patient presented with chronic pelvic pain and menorrhagia. The…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a hysterectomy. In this case, the record establishes that the patient presented with chronic pelvic pain and menorrhagia. The patient has attempted conservative medical treatment with ibuprofen and birth control. Medical literature supports a hysterectomy for the treatment of the patient in this clinical setting. As such, the requested hysterectomy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with a subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-44887

9. Overturned 2025 · Medical necessity · age 41–50 Infertility tx · Genetic conditions The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for in vitro fertilization services. In this case, the record establishes that the patient has a family history of Huntington’s disease and the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for in vitro fertilization services. In this case, the record establishes that the patient has a family history of Huntington’s disease and the inability to conceive. The patient had used all of the frozen embryos, unfortunately, with no live birth. The only available option for this patient was to undergo the additional IVF services in question. As such, the IVF services were medically necessary for the evaluation and treatment of this patient. Final Result: The reviewer determined that the services were medically necessary for the evaluation and treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with a subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

   Case MN25-44772

10. Overturned 2025 · Medical necessity · age 31–40 Laparoscopy · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for any or all of the requested components of the laparoscopic endometrial tissue excision procedure [laparoscopic appendectomy…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for any or all of the requested components of the laparoscopic endometrial tissue excision procedure [laparoscopic appendectomy, laparoscopic excision of endometriosis from the ureters, surgical hysteroscopy, cystourethroscopy to examine urethra, bladder, and ureteric openings, cystourethroscopy with dilation of bladder, diagnostic laparoscopy, abdomen, peritoneum, and omentum, diagnostic proctosigmoidoscopy, rigid, and cystourethroscopy, with ureteroscopy]. All of the requested components of the laparoscopic endometrial tissue excision procedure at issue are indicated for the treatment of this patient. It is not possible to predict ahead of surgery whether any of the requested procedures will actually be needed. The necessity of the procedures will be dictated by the endometriosis surgeon intraoperatively, based on the extent of the endometriosis and the complexity of the surgical resection. Endometriosis can invade into the urinary bladder, ureters, intestines, and other surrounding organs. To safely resect endometriosis lesions in these locations, each of the requested procedures could be helpful. Moreover, endometriosis is known to cause significant adhesion formation and distortion of anatomy. Each of the requested procedures may be required to safely resect adhesions and restore normal anatomy. Finally, the requested procedures would also help to minimize injury to the surrounding organs, thereby reducing complications and need for a potential second operation in the future. For these reasons, all of the requested components of the laparoscopic endometrial tissue excision procedure [laparoscopic appendectomy, laparoscopic excision of endometriosis from the ureters, surgical hysteroscopy, cystourethroscopy to examine urethra, bladder, and ureteric openings, cystourethroscopy with dilation of bladder, diagnostic laparoscopy, abdomen, peritoneum, and omentum, diagnostic proctosigmoidoscopy, rigid, and cystourethroscopy, with ureteroscopy] are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

    Case MN25-44628

11. Upheld 2025 · Medical necessity · age 41–50 Hysterectomy · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a total hysterectomy.The records indicate that this patient complains of heavy menstrual periods. The records do not provide…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a total hysterectomy.The records indicate that this patient complains of heavy menstrual periods. The records do not provide documentation of blood testing, such as hemoglobin and hematocrit, to evaluate the amount of bleeding and the presence of anemia. However, the patient’s endometrial biopsy was benign and showed a polyp, which could be the cause of the patient’s heavy bleeding. The patient’s fibroids are very small, and their location does not suggest a role in the heavy bleeding. Given these findings, the patient is a candidate for treatment with hormonal contraceptives, a Levonorgestrel IUD, Oriahnn or Myfembree, a gonadotropin-releasing hormone (GnRh) agonist, or Tranexamic acid. The records do not indicate that the patient has exhausted these non-invasive options to manage their symptoms. In addition, endometrial ablation can manage the patient’s bleeding if it is determined that excessive bleeding is causing anemia. Therefore, the requested total hysterectomy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested surgery is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

    Case MN25-43712

12. Upheld 2024 · Medical necessity · age 31–40 Other · Kidney and urinary Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total hysterectomy and excision of endometriosis. The records indicate that this patient presents with a history of chronic pelvic pain. In addition, the…

    Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for total hysterectomy and excision of endometriosis. The records indicate that this patient presents with a history of chronic pelvic pain. In addition, the patient reports heavy bleeding with a normal endometrial biopsy. The patient’s records do not include a complete blood count (CBC) to assess the degree of bleeding. The patient’s work-up has not revealed a cause of the patient’s pelvic pain. The patient has requested treatment with a total hysterectomy and excision of endometriosis. Based on the available documentation, there is a lack of indication for these requested procedures. If the problem is the patient’s heavy bleeding, there are multiple options available for treatment prior to proceeding with a hysterectomy including levonorgestrel intrauterine device (IUD), which could be inserted under sedation since the patient is scared to undergo the insertion in the office, tranexamic acid, or endometrial ablation. If the problem is the patient’s chronic pelvic pain, a hysterectomy could either manage the pain or exacerbate it. In addition, there is a lack of reports of an adequate workup to ascertain the etiology of the patient’s pain. Specifically, laparoscopy was not performed, nor was a trial of a gonadotropin-releasing hormone agonist (GnRH) or antagonist to see if it would control the pain. In addition, the patient has diagnoses of anxiety, attention-deficit/hyperactivity disorder (ADHD), anxiety, obsessive-compulsive disorder (OCD), and post-concussive syndrome, and these could be affecting her pain sensation. Overall, it is unlikely that a hysterectomy will help manage the patient’s pain. Therefore, the requested total hysterectomy and excision of endometriosis are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in obstetrics and gynecology with subspecialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s 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.

    Case MN24-42454