Uterine artery embolization or fibroid embolization (37210) is considered medically necessary for the treatment of uterine fibroids when the patient has persistence of one or more symptoms directly attributed to uterine fibroids, i.e., excessive menstrual bleeding (menorrhagia), bulk-related pelvic pain, pressure or discomfort, urinary symptoms referable to compression of the ureter or bladder, and/or dyspareunia and is unresponsive to conservative treatment (e.g., hormonal therapy, D & C, analgesics, endometrial ablation, etc.).

Services that do not meet the medical necessity criteria in this policy may be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Place of Service: Outpatient

Uterine artery embolization for uterine fibroids is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to, current therapeutic anticoagulant therapy or a hematocrit <25%, hemoglobin <8.3 g/dL.

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.

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.

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

InterQual® Level of Care Criteria 2010. Acute Care Adult. McKesson Health Solutions, LLC.