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.
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:
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.
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:
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:
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.
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:
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.
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:
Endometrial ablation with or without hysteroscopic guidance for all other indications is considered not medically necessary.
Covered Diagnosis Codes for Procedure Code 37243 and 58674
Covered Diagnosis Codes for Procedure Codes 37244 and 75894
Non-Covered Diagnosis Codes for Procedure Codes 58578, 58999, 77022 and C1782
Covered Diagnosis Codes for Procedure Codes 58353, 58356 and 58563