Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-114
Topic: Uterine Artery Embolization for Uterine Fibroids
Effective Date: April 1, 2007
Issued Date: September 10, 2007
Date Last Reviewed: 02/2007

General Policy Guidelines

Indications and Limitations of Coverage

Uterine artery embolization or fibroid embolization (37210) is considered an eligible service for the treatment of uterine fibroids (218-218.9) unresponsive to conservative treatment (e.g., hormonal therapy, D & C, analgesics, endometrial ablation, etc.).

Description

Uterine artery embolization (UAE) is a percutaneous technique used in controlling acute and chronic genital bleeding in a wide variety of obstetric and gynecologic disorders (e.g., postpartum hemorrhage, bleeding from ectopic pregnancies, postsurgical bleeding, hemorrhage related to trauma, and the treatment of arteriovenous malformations). Recently, another application for uterine artery embolization has emerged as a treatment for uterine fibroids.

Uterine artery embolization or fibroid embolization is a minimally invasive surgery that shrinks fibroids by cutting off their blood supply. The procedure consists of introduction of a catheter into an artery in either the left arm or the groin under a local anesthetic. Once in the artery, the catheter is manipulated into the uterine arteries and angiography is performed. When the catheter is positioned well within the uterine artery, tiny particles of an embolic agent, (e.g., polyvinyl alcohol) are injected. The embolic agent is carried by the flow of blood into the uterus and the existing fibroids. The particles eventually reach the very small arteries producing blockage, and marked shrinkage of the fibroids. Immediately following the embolization procedure, the catheter is removed and pressure is applied to the entry site to stop any bleeding.


NOTE:
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.

Procedure Codes

37210     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Uterine Artery Embolization for the Treatment of Uterine Fibroids, Current Opinion Obstetrics Gynecology, Volume 10, No. 4, 8/1998

Uterine Arterial Embolization for the Management of Leiomyomas: Quality-of-Life Assessment and Clinical Response, Radiology, Volume 208, No. 3, 9/1998

Uterine Artery Embolization for Fibroid Disease, Cardiovascular Interventional Radiology, Volume 21, No. 5, 9/10/1998

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Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.