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Treatment of Abnormal Uterine Bleeding and Fibroids 2019

Section: Surgery
Effective Date: March 01, 2019
Revised Date: February 13, 2019
Last Reviewed: July 16, 2019

Description

Uterine fibroids are one of the most common conditions affecting women in the reproductive years; symptoms include menorrhagia, pelvic pressure, or pain. Surgery, including hysterectomy and various myomectomy procedures, is considered the criterion standard treatment for symptom resolution. However, there is the potential for surgical complications and, in the case of hysterectomy, the uterus is not preserved. In addition, in the case of multiple uterine fibroids, myomectomy can be a time-consuming procedure. Treatment options include hysterectomy, myomectomy, uterine artery embolization and endometrial ablation.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Treatment of uterine fibroids is considered experimental/investigational and therefore non-covered for ANY ONE of the following procedures/services:

  • Laparoscopic and percutaneous techniques for myolysis (e.g., laser and bipolar needles, cryomyolysis); or
  • Laparoscopic uterine power morcellation in hysterectomy and myomectomy; or
  • MRI guidance performed in conjunction with percutaneous myolysis of uterine fibroids.

The published data regarding techniques of myolysis are inadequate to permit scientific conclusions due to the lack of randomized trials and therefore safety and effectiveness has not been established.

Procedure Codes

0404T 58578 58999 77022

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

  • 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 may be considered medically necessary for the treatment of postpartum uterine hemorrhage.

UAE is considered experimental/investigational for all other indications and therefore non-covered 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

Laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa™) for the treatment of uterine fibroids may be considered medically necessary when the individual is experiencing ANY ONE of the following symptoms:

  • Menorrhagia (excessive menstrual bleeding lasting more than eight (8) days) as a direct result of the fibroid (e.g., 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.

Laparoscopic ultrasound-guided radiofrequency ablation is considered experimental/investigational for all other indications not listed above and therefore noncovered because the safety and/or effectiveness have not been established by the available published peer-reviewed literature.

Procedure Codes

58674

Endometrial ablation with or without hysteroscopic guidance, using an FDA-approved device, may be considered medically necessary in women who would otherwise be considered candidates for hysterectomy when ANY ONE of the following criteria are met:

  • In women with menorrhagia who are not candidates for hormone therapy; or
  • Decline hormone therapy; or
  • Who are unresponsive to hormone therapy.

Endometrial ablation with or without hysteroscopic guidance for all other indications is considered not medically necessary.

Procedure Codes

58353 58356 58563

Outpatient HCPCS (C Codes)

C1782

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 37243 and 58674

D25.0 D25.1 D25.2 D25.9

Covered Diagnosis Codes for Procedure Codes 37244 and 75894

O43.211 O43.212 O43.213 O43.221 O43.222 O43.223 O43.231
O43.232 O43.233 O44.30 O44.31 O44.32 O44.33 O44.50
O44.51 O44.52 O44.53 O72.0 O72.1 O72.2

Non-Covered Diagnosis Codes for Procedure Codes 58578, 58999, 77022 and C1782

D25.0 D25.1 D25.2 D25.9

Covered Diagnosis Codes for Procedure Codes 58353, 58356 and 58563

N92.0 N92.1 N92.4

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