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Treatment is usually sought when the fibroids are associated with menorrhagia, pelvic pain, urinary symptoms (ie, frequency) or are suspected to be the cause of infertility. Treatment options include medical therapy with gonadotropin agonists or gestagen suppression or various types of surgical therapy. Hysterectomy is considered the definitive surgical treatment for those who no longer wish to maintain fertility. Various types of myomectomy, which describes removal of the fibroid with retention of the uterus, have also been described. Hysteroscopic myomectomy involves removal of submucosal fibroids using either a resectoscope or a laser. Subserosal fibroids can be removed via an open abdominal or laparoscopic approach. Laparoscopic laser coagulation of uterine fibroids is a unique approach in that the fibroid is not physically removed, but instead multiple (up to 75) laparoscopic laser punctures of the uterine fibroids are performed in an effort to devascularize the fibroid and induce atrophy. There is interest in techniques to directly devascularize the uterine fibroid by interrupting the uterine arteries. One technique, uterine artery embolization (UAE) involves selective catheterization of the uterine arteries with injection of embolization material.

In November 2002, Embosphere® Microspheres was cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process specifically for use in uterine fibroid embolization. The FDA determined that this device was substantially equivalent to existing devices for use in arterial embolization. Since that time, several other devices such as Coutour® Emboli PVA (September 2003), Contour SE™ (March 2004), and Cook Incorporated Polyvinyl Alcohol Foam Embolization Particles (December 2008) have also received 510(k) marketing clearance for use in uterine fibroid embolization.

There are no specific criteria for uterine artery embolization regarding the size, location or multiplicity of fibroid tumors. The American College of Obstetrics and Gynecology has suggested the following general criteria for treatment of fibroid tumors:

• Asymptomatic fibroid of such size that they are palpable abdominally and are a concern to the patient; OR
• Excessive uterine bleeding as evidenced by either profuse bleeding lasting more than 8 days, or anemia due to acute or chronic blood loss; OR
• Pelvic discomfort caused by myomata, either acute severe pain, chronic lower abdominal pain or low back pressure or bladder pressure with urinary frequency not due to urinary tract infection

Repeat transcatheter embolization of uterine arteries to treat persistent symptoms of uterine fibroids after an initial uterine artery embolization is considered investigational.

None

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

7/16/2001: Hayes report added to the Source(s) section

2/14/2002: Investigational definition added

4/22/2002: Type of Service and Place of Service deleted

5/6/2002: Code Reference section updated

5/2002: Reviewed by MPAC, investigational status remains

8/2002: Reviewed by MPAC, investigational status changed to medically necessary

12/16/2002: Code Reference section updated

8/20/2003: ICD-9 diagnosis code range 218.0-218.9 listed separately

11/5/2003: Code Reference section reviewed; no changes

9/6/2006: Policy reviewed and policy section clarified

3/5/2007: Code Reference section updated per quarterly HCPCS revisions. Added CPT code 37210

1/14/2008: Policy reviewed, no changes

7/18/2008: Anesthesia Coding Policy hyperlink added

1/8/2009: Policy reviewed, no changes

4/27/2010:  Policy Description section revised to add laparoscopic bipolar coagulation of uterine vessels and FDA information.  Code Reference section was revised to add the following language: "*Some covered procedure codes may have multiple descriptions.  Coverage will only be made for covered codes when used for services outlined within the policy statement."  Policy statement unchanged.

05/17/2011: Information regarding laparoscopic occlusion was removed from the policy description and policy statement. Policy statement regarding transcatheter uterine artery embolization unchanged. Policy titled changed from "Uterine Artery Embolization for Treatment of Fibroids" to "Occlusion of Uterine Arteries Using Transcatheter Embolization" to reflect the new scope of the policy. Outdated references removed from the Sources section.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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