Is an operative hysteroscopy with possible polypectomy or lysis of adhesions considered a medical procedure or an excluded infertility service for a patient planning in vitro fertilization (IVF) with a history of iatrogenic abortion, spontaneous abortion (SAB), and suspected uterine scar tissue?

Operative Hysteroscopy with Lysis of Adhesions Should Be Approved as Medically Necessary Treatment

This procedure should be approved as medical treatment for documented intrauterine pathology (adhesions and possible polyp), not denied as an infertility service. The patient has objective findings of intrauterine adhesions on hysterosalpingogram and a filling defect near the left tubal ostia, representing treatable uterine pathology that causes menstrual dysfunction and recurrent pregnancy loss—both recognized medical conditions requiring treatment regardless of future fertility plans 1, 2.

Primary Medical Indications Present

The key distinction here is that hysteroscopic adhesiolysis treats diagnosed uterine pathology (Asherman's syndrome/intrauterine adhesions), not infertility itself 2, 3:

• Intrauterine adhesions are a medical condition characterized by abnormal scar tissue formation that causes menstrual disturbances, recurrent pregnancy loss, and secondary complications including increased risk of placenta accreta in future pregnancies 2
• The patient's history of iatrogenic abortion and spontaneous abortion places her at 16-32% risk of intrauterine adhesions, with risk increasing significantly after multiple pregnancy losses 4
• Hysteroscopic lysis of adhesions is the standard medical treatment for this diagnosed pathology, not an experimental or elective fertility procedure 2, 5

Documentation Supporting Medical Necessity

The clinical documentation clearly establishes medical pathology requiring treatment 6:

• Objective imaging findings: HSG confirmed intrauterine adhesions and a filling defect near the left tubal ostia
• Prior clinical assessment: Previous provider identified suspected scar tissue requiring intervention
• History of pregnancy complications: Iatrogenic abortion and spontaneous abortion are established risk factors for adhesion formation 4
• Potential polyp: The filling defect may represent a polyp, which is also a treatable intrauterine pathology 7

Treatment Restores Normal Anatomy and Function

Hysteroscopic adhesiolysis restores normal uterine anatomy and menstrual function in 81% of patients, which are legitimate medical outcomes independent of fertility goals 3:

• Normal menstrual flow restoration occurs in the majority of treated patients 3
• The procedure prevents progression to more severe adhesions that increase risks of placenta accreta, hemorrhage, and hysterectomy in any future pregnancy 2
• Untreated adhesions pose significant maternal morbidity and mortality risks if pregnancy occurs, including massive hemorrhage requiring transfusion and emergency hysterectomy 2

Distinction from Excluded Infertility Services

The insurance exclusions specifically target procedures performed for the purpose of achieving pregnancy (artificial insemination, IVF, egg harvesting, embryo transfer) [@policy language@]:

• Hysteroscopic adhesiolysis treats diagnosed uterine pathology, not the diagnosis of infertility itself 1, 2
• The procedure would be medically indicated even if the patient never attempted pregnancy, as adhesions cause menstrual dysfunction and increase surgical risks 2, 3
• This is analogous to treating a uterine septum or removing a symptomatic fibroid—the pathology requires treatment regardless of fertility plans 1, 7

Evidence-Based Treatment Standards

Multiple guidelines and research studies establish hysteroscopic adhesiolysis as standard medical care for intrauterine adhesions 2, 5, 3:

• Hysteroscopy is both the diagnostic gold standard and primary treatment method for intrauterine adhesions 2
• The procedure has well-established safety profiles with low complication rates when performed by experienced operators 5, 3
• Pregnancy rates of 22-45% and live birth rates of 28-32% after treatment demonstrate restoration of normal uterine function, not artificial fertility enhancement 2

Critical Timing Considerations

Delaying treatment until after failed IVF attempts would be medically inappropriate 2, 4:

• Adhesions worsen over time without treatment, progressing from mild to severe in many cases 4
• Severe adhesions have 60% re-formation rates even after treatment, making early intervention crucial 3
• Attempting IVF with untreated intrauterine adhesions significantly reduces success rates and increases pregnancy complications 2
• The patient is already 4+ months post-abortion, within the critical window when adhesions typically form and should be addressed 2

Recommended Approval Rationale

The procedure should be approved based on the following medical justifications:

• Documented intrauterine pathology on objective imaging (HSG showing adhesions and filling defect) 6
• Treatment of a medical condition (Asherman's syndrome/intrauterine adhesions) that causes menstrual dysfunction and pregnancy complications 2, 3
• Prevention of maternal morbidity and mortality from untreated adhesions in any future pregnancy (accreta, hemorrhage, hysterectomy risk) 2
• Standard of care treatment supported by multiple medical guidelines and research studies 1, 2, 5, 3
• Not an excluded service: The procedure treats diagnosed uterine pathology, not infertility itself; it would be indicated regardless of fertility plans 1, 2