For a 47‑year‑old woman with prior myomectomies who underwent hysteroscopic polypectomy of two right‑cornual uterine polyps, does the HMO plan classify the procedure as treatment of a benign uterine lesion (and thus covered) or as a conception service (and thus excluded)?

Coverage Determination for Hysteroscopic Polypectomy

The hysteroscopic polypectomy should be classified as treatment of a benign uterine lesion (endometrial polyps) and therefore covered under the plan, not as a conception service. The procedure addresses a documented pathologic finding—two endometrial polyps in the right cornua—which constitutes treatment of an illness or abnormal condition, regardless of the patient's concurrent fertility plans.

Clinical Rationale for Coverage

Polyps as Pathologic Lesions Requiring Treatment

• Endometrial polyps represent benign but abnormal uterine lesions that warrant removal independent of fertility considerations 1, 2.
• The American College of Radiology recognizes hysteroscopic polypectomy as the standard treatment for submucosal lesions and endometrial polyps, particularly when they cause symptoms or are discovered during diagnostic evaluation 3.
• Polyps carry a 3% overall risk of malignancy, with histopathological analysis mandatory after removal to exclude premalignant or malignant pathology 1, 2.

Medical Indications Beyond Conception

The patient has multiple medical indications for polypectomy that exist independently of fertility treatment:

• Abnormal uterine bleeding history: The patient experienced menstrual irregularities (no period for 2 months, hot flashes) documented in the clinical record, which normalized after the previous hysteroscopy 4.
• Incomplete diagnostic evaluation: The left tubal ostium was not visualized during the initial hysteroscopy due to patient pain, making complete cavity assessment medically necessary 4.
• Risk stratification: At age 47 with elevated FSH suggesting perimenopause/menopause, the patient has increased risk factors for endometrial pathology requiring histologic confirmation 1, 2.

Distinction from Conception Services

The key distinction is that polypectomy treats an identified structural abnormality, not infertility itself 5, 3:

• The certificate explicitly states "the diagnosis of infertility alone does not constitute an illness"—but polyps are distinct pathologic lesions, not merely a diagnosis.
• Hysteroscopic polypectomy is indicated for symptomatic patients (abnormal bleeding) and for complete diagnostic evaluation regardless of fertility plans 1, 2.
• In postmenopausal women with polyps and bleeding, polypectomy is recommended specifically to exclude malignancy, demonstrating its role as treatment of disease rather than fertility enhancement 2.

Supporting Evidence from Clinical Guidelines

Standard of Care for Polyp Management

• Hysteroscopic polypectomy is the gold standard treatment for endometrial polyps, with complete removal under hysteroscopic guidance recommended for all symptomatic women 1, 2.
• The procedure has a 93.1% success rate in restoring normal menstruation in patients with abnormal uterine bleeding 6.
• Resectoscopic polypectomy (the planned procedure) has a 0% recurrence rate compared to 15% with other techniques, making it the preferred approach for definitive treatment 6.

Safety Profile and Medical Necessity

• Hysteroscopic polypectomy is a safe, minimally invasive procedure with only 8.7% minor complications and no major complications in large series 6.
• Conservative management (watchful waiting) carries a 25% spontaneous resolution rate, meaning 75% of polyps persist and require intervention 1.
• Expectant management is not recommended in symptomatic patients, and removal is indicated when polyps are discovered during diagnostic evaluation 2.

Common Pitfalls in Coverage Determination

Avoid Conflating Concurrent Conditions

• The fact that a patient is pursuing fertility treatment does not transform treatment of a separate pathologic condition into a conception service 5, 3.
• Many women with fibroids or polyps have concurrent infertility, but the lesions themselves require treatment as independent medical conditions 4.
• The American College of Radiology explicitly distinguishes between treating structural abnormalities (covered) versus assisted reproductive technology procedures (potentially excluded) 5.

Recognize Diagnostic Necessity

• The incomplete visualization of the left cornua during the initial procedure creates a medical necessity for repeat hysteroscopy with complete evaluation 4.
• Mock embryo transfer was performed, but the presence of polyps in the right cornua represents a new finding requiring therapeutic intervention 3.

Algorithmic Approach to Coverage Decision

Step 1: Identify the documented pathology

• Two endometrial polyps in the right cornua confirmed by hysteroscopy 3, 1

Step 2: Determine if the pathology constitutes an illness or abnormal condition

• Polyps are benign tumors requiring histologic evaluation to exclude malignancy 1, 2
• Patient has history of abnormal bleeding that normalized after previous hysteroscopy 4, 1

Step 3: Assess whether the procedure treats the pathology directly

• Hysteroscopic polypectomy is the definitive treatment for endometrial polyps 1, 6, 2
• The procedure addresses the structural abnormality, not infertility per se 3

Step 4: Distinguish from excluded conception services

• The certificate excludes "services designed to assist with conception, fertilization, or impregnation"
• Polypectomy treats an identified lesion; any fertility benefit is secondary 5, 3
• Compare to clearly excluded services: ovulation induction medications, IVF, embryo handling 5

Conclusion: The procedure meets criteria for coverage as treatment of illness (endometrial polyps), not as a conception service.