Should a denial for a hysterosalpingogram (HSG) be reconsidered for a patient with regular periods and previous normal ultrasound results who is trying to conceive?

Clinical Recommendation on HSG Denial Reconsideration

The denial for hysterosalpingogram should be reconsidered and overturned on medical grounds, as HSG is the standard-of-care first-line diagnostic test for evaluating tubal patency in secondary infertility, which directly impacts patient morbidity through delayed diagnosis and treatment of a potentially correctable cause of infertility. 1, 2

Medical Justification for HSG in This Case

Standard-of-Care Diagnostic Testing

• The American College of Radiology explicitly recommends HSG or HyCoSy as first-line tests for evaluating tubal patency due to their less invasive nature and good diagnostic accuracy. 1, 2
• HSG demonstrates 65% sensitivity and 85% specificity for diagnosing tubal patency when compared with laparoscopy, making it the appropriate initial diagnostic modality. 1, 2
• This patient has secondary infertility (previous successful pregnancy in the past, now unable to conceive despite trying since a specific date), which has a high prevalence of tubal factors that HSG is designed to detect. 1

Diagnostic vs. Treatment Distinction

The critical issue here is distinguishing between diagnostic evaluation (which HSG represents) versus fertility enhancement treatments (which the policy excludes):

• HSG is a diagnostic imaging study that evaluates anatomical patency and structural abnormalities, not a fertility enhancement procedure. 1, 2
• The test detects tubal patency, intrauterine adhesions, peritubal disease, and structural abnormalities that may explain infertility. 1, 2
• While HSG has a therapeutic side effect (tubal flushing increases pregnancy rates to 38% vs. 21% without HSG), this is incidental to its primary diagnostic purpose. 1, 2

Clinical Algorithm Supporting HSG

For secondary infertility evaluation, the evidence-based diagnostic pathway is:

1. Initial transvaginal ultrasound (already completed in this patient and was normal) to assess ovarian reserve and detect obvious pathology. 1
2. HSG or HyCoSy as the next step to evaluate tubal patency, given the high prevalence of tubal factors in secondary infertility. 1
3. Further invasive testing (laparoscopy, hysteroscopy) only if HSG reveals abnormalities or remains inconclusive. 3, 1

Impact on Morbidity and Quality of Life

Denying HSG creates significant clinical harm:

• Delayed diagnosis of tubal occlusion forces patients toward more invasive diagnostic procedures (laparoscopy) or expensive treatments (IVF) without knowing if simpler interventions could succeed. 4
• Tubal catheterization following HSG diagnosis of proximal tubal obstruction achieves 72.4% success in opening tubes, with 36.1% of these patients achieving pregnancy, demonstrating that early diagnosis enables less invasive treatment. 4
• The patient has regular periods and normal ultrasound, making tubal factors a primary remaining diagnostic consideration that cannot be evaluated without HSG or equivalent testing. 1

Alternative Considerations

If HSG Remains Denied

If the administrative denial cannot be overturned, the only alternatives are:

• HyCoSy (hysterosalpingo-contrast sonography) has similar accuracy to HSG (91% accuracy) and may be covered under different billing codes as an ultrasound-based procedure rather than fluoroscopy. 1, 2
• Direct referral to laparoscopy, which is more invasive, carries surgical risks, requires anesthesia, but definitively evaluates tubal patency and treats endometriosis if present. 1, 2

Important Caveats

• If HSG is performed and hydrosalpinx or history of pelvic inflammatory disease is present, antibiotic prophylaxis should be considered, as post-HSG infection rates can reach 3.1% in high-risk patients. 5
• HSG has limited accuracy (16.7%) for categorizing Müllerian duct anomalies compared to MRI (100% accuracy), so if congenital anomalies are suspected based on history, MRI may be more appropriate. 1
• HSG interpretation has significant observer variability (kappa 0.345-0.430), so films should be reviewed by experienced clinicians rather than relying solely on radiology reports. 6

The policy language excluding "infertility testing" appears to conflate diagnostic evaluation with fertility enhancement treatments, but HSG serves as essential diagnostic imaging to identify anatomical pathology, similar to how mammography diagnoses breast disease rather than treats it.