Medical Procedure Classification
The requested hysteroscopy with D&C and polypectomy should be classified as a medical procedure, not a conception care benefit, because the primary indication is treatment of structural uterine pathology (endometrial polyp and intrauterine synechiae) causing abnormal uterine bleeding—not infertility treatment itself. 1, 2
Rationale for Medical Classification
Primary Medical Indications Present
Abnormal uterine bleeding with structural pathology: The patient has irregular periods with spotting for 3 cycles, and imaging demonstrates multiple endometrial filling defects including a 10mm polyp and intrauterine synechiae 2, 3
Diagnostic imperative: Blind D&C should be avoided, but hysteroscopy with directed biopsy has the highest diagnostic accuracy for evaluating endometrial pathology and is the standard of care when focal lesions are identified 1, 4, 5
Malignancy exclusion: Endometrial polyps in reproductive-age women with abnormal bleeding require histologic examination to exclude premalignant or malignant conditions, which occurs in a small but significant percentage of cases 3, 5
Treatment of Structural Abnormalities
Polypectomy indication: Hysteroscopic polypectomy is indicated for symptomatic endometrial polyps causing abnormal uterine bleeding, independent of fertility concerns 3, 4, 5
Synechiae treatment: Intrauterine adhesions (synechiae) visualized on imaging require hysteroscopic lysis, which is the standard therapeutic approach for this structural abnormality 6, 7
Standard gynecologic care: These procedures represent standard treatment for diagnosed uterine pathology causing symptoms, not experimental or investigational fertility treatments 1, 5
Why This Is NOT Conception Care
Conception Services Definition Analysis
The benefit language specifies: "Services designed to assist Members with conception, fertilization or impregnation" - this procedure is designed to treat bleeding and structural pathology, not directly assist with conception [@benefit language provided]
Fertility is secondary: While removing polyps and synechiae may improve fertility outcomes, the primary medical indication is treatment of abnormal bleeding and exclusion of malignancy [@6@, 5]
Not assisted reproduction: The procedure does not involve handling of eggs or embryos, which the plan specifically defines as requiring conception benefit coverage [@benefit language provided]
Clinical Precedent
Standard diagnostic workup: Hysteroscopy with D&C and polypectomy represents the standard diagnostic and therapeutic approach for abnormal uterine bleeding with identified structural lesions, regardless of fertility desires 1, 2, 4
Would be performed even without fertility concerns: A postmenopausal woman with the same findings would receive identical treatment, confirming this is medical management of uterine pathology 5
Common Pitfalls to Avoid
Do not conflate fertility preservation with fertility treatment: Treating medical conditions that happen to affect fertility does not automatically make them conception services 1, 5
The thyroid issue is a red herring: The instruction to avoid pregnancy until thyroid stabilization further supports that this is medical management, not active conception assistance [@clinical scenario]
Timing matters: The patient was "attempting pregnancy" but is now advised to avoid it—the procedure addresses the medical pathology discovered during evaluation, not ongoing fertility treatment [@clinical scenario]