Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Uterine Artery Embolization

Policy #:11.06.04j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Uterine artery embolization (UAE) is considered medically necessary and, therefore, covered as a treatment for women with uterine fibroids when EITHER of the following criteria is met:
  • The individual is experiencing symptoms, such as but not limited to:
    • Menorrhagia (excessive menstrual bleeding) as a direct result of the fibroid (i.e., not resulting from hyperplasia, atypia, or cancer) that interferes with daily activities or causes anemia
    • Pelvic pain or pressure as a direct result of the fibroid
    • Lower back pain as a direct result of the fibroid
    • Urinary symptoms related to compression of the bladder (e.g., urinary frequency, urgency)
    • Gastrointestinal symptoms related to compression of the bowel (e.g., constipation, bloating) as a direct result of the fibroid
    • Dyspareunia (painful or difficult sexual relations) as a direct result of the fibroid
  • The individual is asymptomatic with an abdominally palpable fibroid or significantly enlarged fibroid on abdominal/vaginal examination

Uterine artery embolization (UAE) is considered medically necessary and, therefore, covered as a treatment for postpartum uterine hemorrhage.

Repeat UAE may be considered medically necessary and, therefore, covered to treat symptoms of uterine fibroids that persist after an initial uterine artery embolization.

UAE is considered experimental/investigational and, therefore, not covered for any of the following because the safety and/or effectiveness of UAE for these individuals has not been established by a review of the available published peer-reviewed literature:
  • Treatment of an individual who may want to become pregnant. Please refer to the Guidelines section of this policy for further clarification.
  • Management of cervical ectopic pregnancy
  • Treatment of adenomyosis

ABSOLUTE CONTRAINDICATIONS

UAE is considered not medically necessary and, therefore, not covered for individuals with any of the following absolute contraindications:
  • Cancers of the endometrium, cervix, or ovaries
  • Pregnancy
  • Active infection

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

UAE is appropriate as a treatment for women with symptomatic uterine fibroids who meet any of the following criteria:
  • The use of anesthesia places the individual at high surgical risk.
  • The individual has medical contraindications to hysterectomy (e.g., morbid obesity).
  • The use of hormonal therapy is contraindicated, or the individual is intolerant to or has previously failed a course of hormone therapy.
  • The individual wishes to avoid hysterectomy.
  • The individual has hydronephrosis.

Individuals who have received a gonadotropin-releasing hormone (GnRH) agonist to shrink uterine fibroids should not receive treatment with UAE until six weeks post-GnRH agonist treatment. Uterine artery embolization (UAE) performed earlier than six weeks after hormone therapy may not be effective.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, uterine artery embolization (UAE) for the treatment of uterine fibroids is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company. Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

When UAE is performed on an individual who has any of the absolute contraindications listed in this policy, it is considered not medically necessary and, therefore, not covered.

DESIRED FERTILITY

UAE may be appropriate as a treatment for individuals who want to become pregnant or who desire fertility because these women may not be candidates for other treatment options such as hormonal therapy, myomectomy, or hysterectomy. However, studies have shown that individuals who are treated with UAE are at increased risk for complications and miscarriages in subsequent pregnancies. Diminished ovarian reserve and increased risk for complications such as post-delivery bleeding have been noted.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The US Food and Drug Administration (FDA) has approved several devices for UAE.

Description

Uterine fibroids (leiomyomas) are extremely common benign tumors that are located within the uterine cavity (submucosal fibroids), on the serosal surface of the uterus (subserosal), within the body of the uterine musculature (intramural fibroids), and on a stalk inside or outside the uterus (pedunculated).

Uterine fibroids may be asymptomatic but can cause menorrhagia (excessive menstrual bleeding), pelvic pain, dyspareunia (painful or difficult sexual relations), lower back pain, constipation, urinary frequency, or infertility. Although hysterectomy is considered the definitive treatment of uterine fibroids, it may not be a viable option for individuals who wish to maintain fertility or are at high risk for surgery.

Transcatheter uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE), is a minimally invasive, uterine-sparing treatment option for individuals with uterine fibroids. UAE has several advantages over conventional hormonal suppression and surgical procedures, including: avoiding the side effects of drug therapy and the trauma of surgery; lower rate of morbidity; and shorter recovery time. Along with hysteroscopic resection, myolysis, and laparoscopic myomectomy, UAE widens the treatment options for individuals requiring treatment without hysterectomy.

During UAE, the uterine fibroid tumor is selectively devascularized by an injection of embolic agents (e.g., Embosphere® Microspheres) into the vessels that provide the blood supply to the tumor. While the individual is under sedation, a catheter is guided, under fluoroscopy, from the femoral artery (accessed through a percutaneous puncture site in the groin) to the uterine artery that supplies blood to the fibroid. When the catheter reaches the uterine artery, the embolic material is slowly released into the artery. The particles flow to the fibroids, wedge into the vessel, and block the blood flow, causing the fibroids to shrink while sparing surrounding uterine structures. As the fibroids shrink, the pre-procedure symptoms are relieved or reduced.

In most cases, UAE is performed bilaterally and requires overnight hospitalization. During or following the procedure, angiography is performed to assess the effectiveness of the procedure. A radiopaque contrast medium is injected through the catheter used during the procedure, and fluoroscopic images of the vessel are recorded. The images are interpreted to evaluate the status of the blood vessel and the effectiveness of the treatment.

UAE is also used as a treatment of postpartum hemorrhage. Per ACOG Practice Bulletin #183 (2017), candidates for UAE typically are hemodynamically stable, appear to have persistent slow bleeding and have failed less invasive therapy (e.g. uterotonic agents, uterine massage, uterine compression, and manual removal of any clots).

ACOG issued a Practice Bulletin on Alternatives to Hysterectomy in the Management of Leiomyomas in 2008 (Reaffirmed in 2016). The concerns identified for women intending to become pregnant after UAE include age-related impairment of ovarian function and placentation problems caused by a potential compromise of the blood supply to the ovary and endometrium, which can lead to diminished ovarian reserve and abnormal placentation, respectively, even in women who are otherwise not at risk for these problems. Therefore, UAE in a woman wishing to become pregnant post-procedure should be approached with caution; these potential risks must be fully disclosed.

The effect of UAE on pregnancy remains understudied. Although systematic reviews of fertility and pregnancy outcomes after UAE suggest that successful pregnancy is possible, there are higher rates of miscarriage and postpartum hemorrhage compared to women with intramural fibroids treated with myomectomy. There are limited data on pregnancy outcomes in women who became pregnant following UAE for treatment of postpartum hemorrhage.

Few studies have been reported that focus specifically on repeat UAE in individuals whose symptoms have either responded incompletely or recurred after the initial UAE. Although there is a lack of controlled studies on repeat UAE, several case series have reported a high success rate after a second UAE for recurrent or persistent systems.

UAE has been proposed for management of cervical ectopic pregnancy, adenomyosis and uterine arteriovenous malformations; however, there are no controlled studies evaluating UAE for management of cervical ectopic pregnancy or uterine arteriovenous malformations.
References


Al-Mahrizi S, Tulandi T. Treatment of uterine fibroids for abnormal uterine bleeding: myomectomy and uterine artery embolization. Best Pract Res Clin Obstet Gynaecol 2007;21(6):995-1005.

Ambat S, Mittal S, Srivastava DN, et al. Uterine artery embolization versus laparoscopic occlusion of uterine vessels for management of symptomatic uterine fibroids. Int J Gynecol Obstet. 2009;105(2):162-5.

American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin 76: Postpartum hemorrhage. Obstet Gynecol. 2006;108(4): 1039-1047. Reaffirmed 2015. (Replaced by Practice Bulletin 183).

American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin 96: Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387-400. Reaffirmed 2016.

American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Bulletin 183: Postpartum Hemorrhage. Obstet Gynecol. 2017; 130(4):e168-e186.

American College of Obstetricians and Gynecologists (ACOG). Commitee Opinion No. 293: Uterine artery embolization. Obstet Gynecol. 2004;103(2):403-4. (Replaced by Practice Bulletin 96).

American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. Obstet Gynecol. 2013;121:891–6. Reaffirmed 2017.

Bae SH, Kim MD, Kim GM, et al. Uterine artery embolization for adenomyosis: percentage of necrosis predicts midterm clinical recurrence. J Vasc Interv Radiol. 2015;26(9):1290-1296 e1292.

Barnard EP, AbdElmagied AM, Vaughan LE, et al. Periprocedural outcomes comparing fibroid embolization and focused ultrasound: a randomized controlled trial and comprehensive cohort analysis. Am J Obstet Gynecol. 2017;216(5):500 e501-500 e511.

Barral PA, Saeed-Kilani M, Tradi F, et al. Transcatheter arterial embolization with ethylene vinyl alcohol copolymer (Onyx) for the treatment of hemorrhage due to uterine arteriovenous malformations. Diagn Interv Imaging. 2017;98(5):415-421.

BioSphere Medical. Uterine fibroid embolization. [BioSphere Medical Web site]. Available at: http://www.ask4ufe.com/howUfeHelps/ufeProcedure.cfm. Accessed December 21, 2017.

BlueCross BlueShield Association (BCBSA). Technology Evaluation Center. Uterine artery embolization for the treatment of symptomatic uterine fibroids [technology assessment]. Assessment Program 2002; Volume 17, Tab 8.

Broder MS, Goodwin S, Chen G, et al. Comparison of long-term outcomes of myomectomy and uterine artery embolization. Obstet Gynecol. 2002;100(5 pt 1):864-868.

Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Therapeutic EMBOLIZATION (20.28). Original: 12/15/1978. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=52&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Pennsylvania&KeyWord=embolization&KeyWordLookUp=Title&KeyWordSearchType=And&from2=search.asp&bc=gAAAABAAAAAAAA%3d%3d&. Accessed December 21, 2017.

Dariushnia SR, Nikolic B, Stokes LS, et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol. 2014;25(11):1737-47.

Das R, Champaneria R, Daniels JP, et al. Comparison of Embolic Agents Used in Uterine Artery Embolisation: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol. 2014;37(5):1179-90.

de Bruijn AM, Ankum WM, Reekers JA, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 10-years' outcomes from the randomized EMMY trial. Am J Obstet Gynecol. 2016 ;215(6):745.e1-745.e12.

de Bruijn AM, Smink M, Hehenkamp WJK, et al. Uterine artery embolization for symptomatic adenomyosis: 7- year clinical follow-up using UFS-Qol Questionnaire. Cardiovasc Intervent Radiol. 2017;40(9):1344-1350.

Domenico L Jr, Siskin GP. Uterine artery embolization and infertility. Tech Vasc Interv Radiol. 2006;9(1):7-11.

Doumouchtsis SK, Nikolopoulos K, Talaulikar V, et al. Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review. BJOG. 2014;121(4):382-8.

Edwards RD, Moss JG, Lumsden MA, et al.; Committee of the Randomized Trial of Embolization versus Surgical Treatment for Fibroids. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med. 2007;356(4):360-70.

Ganguli S, Stecker MS, Pyne D, et al. Uterine artery embolization in the treatment of postpartum uterine hemorrhage. J Vasc Interv Radiol. 2011;22(2):169-76.

Goldberg J, Pereira L, Berghella V. Pregnancy after uterine artery embolization. Obstet Gynecol. 2002;100(5 pt 1):869-872.

Goldberg J, Pereira L, Berghella V, et al. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol. 2004;191(1):18-21.

Goodwin SC, Spies JB, Worthington-Kirsch R, et al. Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. Obstet Gynecol. 2008;111(1):22-23.

Gupta JK, Sinha AS, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database of Syst Rev.2012 May 16; 5:CD005073.

Hald K, Klow NE, Qvigstad E, et al. Laparoscopic occlusion compared with embolization of uterine vessels: a randomized controlled trial. Obstet Gynecol.2007;109(1):20-7.

Hald K, Langebrekke A, Klow NE, et al. Laparoscopic occlusion of uterine vessels for the treatment of symptomatic fibroids: initial experience and comparison to uterine artery embolization. Am J Obstet Gynecol. 2004;190(1):37-43.

Hald K, Noreng, Istre O, et al. Uterine artery embolization versus laparoscopic occlusion of uterine arteries for leiomyomas: Long-term results of a randomized comparative trial. J Vasc Interv Radiol. 2009;20(10):1303-10.

Hehenkamp WJ, Volkers NA, Donderwinkel PF, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): Peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol. 2005;193(5):1618-1629.

Hirst A, Dutton S, Wu O, et al. A multi-centre retrospective cohort study comparing the efficacy, safety, and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technol Assess. 2008;12(5):1-248, iii.

Holub Z, Eim J, Jabor A, et al. Complications and myoma recurrence after laparoscopic uterine artery occlusion for symptomatic myomas. J Obstet Gynaecol Res. 2006;32(1):55-62.

Homer H, Saridogan E. Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril. 2010;94(1):324-30.

Hu J, Tao X, Yin L, et al. Successful conservative treatment of cervical pregnancy with uterine artery embolization followed by curettage: a report of 19 cases. BJOG. 2016;123 Suppl 3:97-102.

Jun F, Yamin L, Xinli X, et al. Uterine artery embolization versus surgery for symptomatic uterine fibroids: a randomized controlled trial and a meta-analysis of the literature. Arch Gynecol Obstet. 2011;285(5):1407-13.

Kandinov L, Berbstein P. Field notes in obstetrics and maternal-fetal medicine. Uterine artery embolization for treatment of fibroids: effect on fertility and pregnancy outcomes. [Medscape Web site]. January 3, 2005. Available at: http://www.medscape.com/viewarticle/496253 [via subscription only]. Accessed December 21, 2017.

Kim D, Baer SD. Interventional radiology in management of gynecological disorders. 01/15/2016. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed December 21, 2017.

Kim D, Baer SD. Uterine leiomyoma (fibroid) embolization. 06/05/2014. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. [The link to this reference is no longer active on the UpToDate Web site.]. Accessed October 7, 2016.

Kim TH, Lee HH, Kim JM, et al. Uterine artery embolization for primary postpartum hemorrhage. Iran J Reprod Med. 2013;11(6):511-8.

Kim T, Shin JH, Kim J, et al. Management of bleeding uterine arteriovenous malformation with bilateral uterine artery embolization. Yonsei Med J. 2014;55(2):367-73.

Kirby JM, Kachura JR, Rajan DK, et al. Arterial embolization for primary postpartum hemorrhage. J Vasc Interv Radiol. 2009;20(8):1036-45.

Kwon JH, Kim GM, Han K, et al. Safety and efficacy of uterine artery embolization in ectopic pregnancies refractory to systemic methotrexate treatment: a single-center study. Cardiovasc Intervent Radiol. 2017; 40(9):1351-1357.

Liu WM. Laparoscopic bipolar coagulation of uterine vessels to treat symptomatic leiomyomas. J Am Assoc Gynecol Laparosc. 2000;7(1):125-129.

Liu WM, Ng HT, Wu YI, et al. Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids. Fertil Steril. 2001;75(2):417-422.

Manyonda IT, Bratby M, Horst JS, et al. Uterine artery embolization versus myomectomy: Impact on quality of life-results from the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) trial. Cardiovasc Intervent Radiol. 2012; 35(3):530-6.

Mara M, Maskova J, Fucikova Z, et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008; 31(1):73-85.

Marshburn PB, Matthews ML, Hurst BS. Uterine artery embolization as a treatment option for uterine myomas. Obstet Gynecol Clin N Am. 2006;33(1):125-144.

Martin J, Bhanot K, Athreya S. Complications and reinterventions in uterine artery embolization for symptomatic uterine fibroids: a literature review and meta analysis. Cardiovasc Intervent Radiol. 2013; 36(2):395-402.

McLucas B, Reed RA. Repeat uterine artery embolization following poor results. Minim Invasive Ther Allied Technol. 2009;18(2):82-6.

McPherson K, Manyonda I, Lumsden MA, et al. A randomised trial of treating fibroids with either embolisation or myomectomy to measure the effect on quality of life among women wishing to avoid hysterectomy (the FEMME study): study protocol for a randomised controlled trial. Trials. 2014;15:468.

Mohan PP, Hamblin MH, Vogelzang RL. Uterine artery embolization and its effect on fertility. J Vasc Interv Radiol. 2013; 24(7):925-30.

Moss JG, Cooper CG, Khaund A, et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG. 2011; 118(8):936-44.

National Guideline Clearinghouse (NGC). Guideline summary: Alternatives to hysterectomy in the management of leiomyomas. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2000 May (Revised 2008 Aug; Reaffirmed 2012; Archived).

Popovic M, Berzaczy D, Puchner S, et al. Long-term quality of life assessment among patients undergoing uterine fibroid embolization. AJR Am J Roentgenol. 2009;193(1):267-71.

Popovic M, Puchner S, Berzaczy D, et al. Uterine artery embolization for the treatment of adenomyosis: a review. J Vasc Interv Radiol. 2011;22(7):901-909; quiz 909.

Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society of Reproductive Surgeons. Myomas and reproductive function. Fertil Steril. 2008;90(5 Suppl):S125-S130.

Pron G, Bennett J, Common A, et al. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril. 2003;79(1):120-127.

Rath W, Hackethal A, Bohlmann MK. Second-line treatment of postpartum haemorrhage (PPH). Arch Gynecol Obstet. 2012; 286(3):549-61.

Razavi MK, Wolanske KA, Hwang GL, et al. Angiographic classification of ovarian artery-to-uterine artery anastomoses: initial observations in uterine fibroid embolization. Radiology. 2002;224(3):707-712.

Ruuskanen A, Hippelainen M, Sipola P, et al. Uterine artery embolisation versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomized prospective clinical trial. Eur Radiol. 2010; 20(10):2524-32.

Sathe NA, Likis FE, Young JL, et al. Procedures and uterine-sparing surgeries for managing postpartum hemorrhage: a systematic review. Obstet Gynecol Surv.2016;71(2):99-113.

Shlansky-Goldberg RD, Rosen MA, Mondschein JI, et al. Comparison of polyvinyl alcohol microspheres and tris-acryl gelatin microspheres for uterine fibroid embolization: results of a single-center randomized study. J Vasc Interv Radiol. 2014;25(6):823-32.

Society of Obstetricians and Gynaecologists of Canada (SOGC). SOGC clinical practice guidelines. Uterine fibroid embolization (UFE). Number 150, October 2004. Int J Gynaecol Obstet. 2005;89(3):305-318.

Spies JB, Spector A, Roth AR, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol. 2002;100(5 pt 1):873-880.

Stewart EA. Overview of treatment of uterine leiomyomas (fibroids). 11/30/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed December 21, 2017.

Stokes LS, Wallace MJ, Godwin RB, et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. J Vasc Interv Radiol. 2010; 21(8):1153-63.

The FIRSST: Comparing MRgFUS (MR guided Focused Ultrasound) versus UAE (Uterine Artery Embolization) (NCT00995878). Last updated 11/09/2017. Available at: http://www.clinicaltrials.gov/ct2/show/NCT00995878. Accessed December 21, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Contour® Emboli PVA and FasTracker®325 Infusion Catheter. Summary of safety and effectiveness. [FDA web site.] 09/23/03. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf3/K030966.pdf. Accessed December 21, 2017.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Embosphere® Microspheres for use in uterine fibroid embolization. 510(k) summary. [FDA Web site]. 11/22/02. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf2/k021397.pdf. Accessed December 21, 2017.

US Food and Drug Administration (FDA). FDA Talk Paper. T02-48: FDA clears device to treat fibroids. [FDA Web site]. 11/27/02. Available at: http://www.scienceblog.com/community/older/archives/M/1/fda0783.htm. Accessed December 21, 2017.

Uterine Artery Embolization (UAE) Versus High-Intensity-Focused-Ultrasound (HIFU) for Treatment of Uterine Fibroids (NCT01834703). Last updated 08/22/2017. Sponsored by the Chinese University of Hong Kong. Available at: https://clinicaltrials.gov/ct2/show/NCT01834703. Accessed December 21, 2017.

van der Kooij SM, Hehenkamp WJ, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2010; 203(2):105.e1-13.

van der Kooij SM, Bipat S, Hehenkamp WJ, et al. Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and meta-analysis. Am J Obstet Gynecol. 2011;205(4):317.e1-8.

van der Kooij SM, Hehenkamp WJK. Uterine leiomyomas (fibroids): Treatment with uterine artery embolization. 01/06/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed December 21, 2017.

Vilos GA, Allaire C, Laberge PY, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015;37(2):157-181.

Volkers NA, Hehenkamp WJ, Birnie E, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2007;196(6):519.

Walker WJ, Barton-Smith P. Long-term follow up of uterine artery embolisation: an effective alternative in the treatment of fibroids. BJOG. 2006;113(4):464-468.

Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up. BJOG. 2002;109(11):1262-1272.

Wang S, Meng X, Dong Y. The evaluation of uterine artery embolization as a nonsurgical treatment option for adenomyosis. Int J Gynaecol Obstet. 2016;133(2):202-205.

Xiaolin Z, Ling L, Chengxin Y, et al. Transcatheter intraarterial methotrexate infusion combined with selective uterine artery embolization as a treatment option for cervical pregnancy. J Vasc Interv Radiol. 2010;21(6):836-41.

Yoon DJ, Jones M, Taani JA, et al. A systematic review of acquired uterine arteriovenous malformations: pathophysiology, diagnosis, and transcatheter treatment. AJP Rep. 2016;6(1):e6-e14.

Yousefi S, Czeyda-Pommersheim F, White AM, et al. Repeat uterine artery embolization: indications and technical findings. J Vasc Interv Radiol. 2006;17(12):1923-9.

Zhou J, He L, Liu P, et al. Outcomes in adenomyosis treated with uterine artery embolization are associated with lesion vascularity: a long-term follow-up study of 252 cases. PLoS One. 2016;11(11):e0165610.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

36245, 36246, 36247, 36248, 37243


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

D25.0 Submucous leiomyoma of uterus
D25.1 Intramural leiomyoma of uterus
D25.2 Subserosal leiomyoma of uterus
D25.9 Leiomyoma of uterus, unspecified
O72.0 Third-stage hemorrhage
O72.1 Other immediate postpartum hemorrhage
O72.2 Delayed and secondary postpartum hemorrhage



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Revisions from 11.06.04j:
04/11/2018This policy has undergone routine review, and no revisions have been made.

Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/01/2016
Version Issued Date: 09/30/2016
Version Reissued Date: 04/11/2018

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