Prior Authorization

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Procedures

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:

·         The individual is experiencing the following symptoms:

o    Menorrhagia (excessive menstrual bleeding lasting more than eight (8) days) as a direct result of the fibroid (i.e., not resulting from hyperplasia, atypia, or cancer) that interferes with daily activities or causes anemia; or

o    Pelvic pain or pressure as a direct result of the fibroid; or

o    Lower back pain as a direct result of the fibroid; or

o    Urinary symptoms (e.g., urinary frequency, urgency) related to compression of the bladder as a direct result of the fibroid; or

o    Gastrointestinal symptoms related to compression of the bowel (e.g., constipation, bloating) as a direct result of the fibroid; or

o    Dyspareunia (painful or difficult sexual relations) as a direct result of the fibroid; or

o    An abdominally palpable fibroid; or

o    Postpartum uterine hemorrage; or

o    Placenta accreta, placenta increta or placenta percreta.

Or

·         The individual is asymptomatic with an abdominally palpable fibroid or significantly enlarged fibroid on abdominal/vaginal examination and any ONE of the following:

o    The use of anesthesia places the individual at high surgical risk; or

o    The individual has medical contraindications to hysterectomy (e.g., morbid obesity); or

o    The use of hormonal therapy is contraindicated, or the individual is intolerant to or has previously failed a course of hormone therapy; or

o    The individual wishes to avoid hysterectomy; or

o    The individual may want to become pregnant; or

o    The individual has hydronephrosis.

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:

·         Documentation of continued symptoms such as bleeding or pain; or

·         Individual has persistent symptoms in combination with findings on imaging of an incomplete initial procedure, as evidenced by continued blood flow to the treated regions.

UAE may be considered medically necessary for the treatment of postpartum uterine hemorrhage.

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation (e.g., Acessa™, Sonata) for the treatment of uterine fibroids may be considered medically necessary when the individual is experiencing any ONE of the following symptoms:

·         Menorrhagia (excessive menstrual bleeding lasting more than eight (8) days) as a direct result of the fibroid (e.g., not resulting from hyperplasia, atypia, or cancer) that interferes              with daily activities or causes anemia; or

·         Pelvic pain or pressure as a direct result of the fibroid; or

·         Lower back pain as a direct result of the fibroid; or

·         Urinary symptoms (e.g., urinary frequency, urgency) related to compression of the bladder as a direct result of the fibroid; or

·         Gastrointestinal symptoms related to compression of the bowel (e.g., constipation, bloating) as a direct result of the fibroid; or

·         Dyspareunia (painful or difficult sexual relations) as a direct result of the fibroid; or

·         An abdominally palpable fibroid.

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered 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 is met:

·         In women with menorrhagia who are not candidates for hormone therapy; or

·         Decline hormone therapy; or

·         Who are unresponsive to hormone therapy.

Endometrial ablation with or without hysteroscopic guidance for all other indications is considered not medically necessary.

Treatment of uterine fibroids is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature for any ONE of the following procedure/services.

• Laparoscopic and percutaneous techniques for myolysis (e.g., laser and bipolar needles, cryomyolysis); or
• Laparoscopic uterine power morcellation in hysterectomy and myomectomy; or
• MRI guidance performed in conjunction with percutaneous myolysis of uterine fibroids. 

Post Payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Place of Service: Outpatient

Experimental/investigational (E/I) services are not covered regardless of place of service.

Treatment of 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, the presence of a comorbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract.