Criteria
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date;
or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Coverage is subject to the specific terms of the member's benefit plan.
Transcatheter uterine artery embolization (UAE) of uterine arteries may be considered medically necessary for the treatment of uterine fibroids when any
ONE
of the following criteria is met:
-
The individual is experiencing the following symptoms:
-
Menorrhagia (excessive menstrual bleeding lasting more than eight (8) days) as a direct result of the fibroid (i.e., not resulting from hyperplasia, atypia, or cancer) that interferes with daily activities or causes anemia;
or
-
Pelvic pain or pressure as a direct result of the fibroid;
or
-
Lower back pain as a direct result of the fibroid;
or
-
Urinary symptoms (e.g., urinary frequency, urgency) related to compression of the bladder as a direct result of the fibroid;
or
-
Gastrointestinal symptoms related to compression of the bowel (e.g., constipation, bloating) as a direct result of the fibroid;
or
-
Dyspareunia (painful or difficult sexual relations) as a direct result of the fibroid;
or
-
An abdominally palpable fibroid;
or
-
Postpartum uterine hemorrhage;
or
- Placenta accreta, placenta increta or placenta percreta
Or
-
The individual is asymptomatic with an abdominally palpable fibroid or significantly enlarged fibroid on abdominal/vaginal examination and any
ONE
of the following:
-
The use of anesthesia places the individual at high surgical risk;
or
-
The individual has medical contraindications to hysterectomy (e.g., morbid obesity)
; or
-
The use of hormonal therapy is contraindicated, or the individual is intolerant to or has previously failed a course of hormone therapy;
or
-
The individual wishes to avoid hysterectomy;
or
-
The individual may want to become pregnant;
or
- The individual has hydronephrosis.
One repeat transcatheter embolization of uterine arteries may be considered medically necessary to treat persistent symptoms of uterine fibroids after an initial uterine artery embolization when any
ONE
of the following criteria is met:
-
Documentation of continued symptoms such as bleeding or pain;
or
- Individual has persistent symptoms in combination with findings on imaging of an incomplete initial procedure, as evidenced by continued blood flow to the treated regions.
UAE not meeting the criteria as indicated in this policy is considered experimental/investigational, because the safety and/or effectiveness have not been established by the available published peer-reviewed literature.
Procedure Codes
| 36245 | 36246 | 36247 | 36248 | 37243 | 37244 | 75894 |
