HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-179-024
Topic:
Treatment of Abnormal Uterine Bleeding and Uterine Fibroids
Section:
Surgery
Effective Date:
January 1, 2024
Issued Date:
January 8, 2024
Last Revision Date:
December 2023
Annual Review:
May 2023
 
 

Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is bleeding from the uterus between periods. It may also be prolonged bleeding during a period or an extremely heavy period (menorrhagia).

Uterine Fibroids

Uterine fibroids are noncancerous growths of the uterus. Symptoms may include menorrhagia, pelvic pressure or pain. Treatment options include hysterectomy, myomectomy, uterine artery embolization and fibroid ablation.

Policy Position

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:
    • 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 
    • 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; or
    • Postpartum uterine hemorrage; or
    • 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:
    • The use of anesthesia places the individual at high surgical risk; or
    • The individual has medical contraindications to hysterectomy (e.g., morbid obesity); or
    • The use of hormonal therapy is contraindicated, or the individual is intolerant to or has previously failed a course of hormone therapy; or
    • The individual wishes to avoid hysterectomy; or
    • The individual may want to become pregnant; or
    • 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 not meeting the criteria as indicated in this policy is considered experimental/investigational because the safety and/or effectiveness have not been established by the available published peer-reviewed literature.

 

36245

36246

36247

36248

37243

37244

75894


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: 

  • 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.

58674

58580

 

 

 

 

 


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 not meeting the criteria as indicated in this policy, is considered not medically necessary. 

58353

58356

58563

 

 

 

 


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. 

58578

58999

77022

        


C1782

 

 

 

 

 

 


Covered Diagnosis Codes for Procedure Code 58674 and 58580

D25.0

D25.1

D25.2

D25.9

 

 

 

 

Covered Diagnosis Codes for Procedure Code75894

O43.211

O43.212

O43.213

O43.221

O43.222

O43.223

O43.231

O43.232

O43.233

O44.30

O44.31

O44.32

O44.33

O44.50

O44.51

O44.52

O44.53

O72.0

O72.1

O72.2

 

 

Non-Covered Diagnosis Codes for Procedure Codes 58578, 58999, 77022, C1782

D25.0

D25.1

D25.2

D25.9

 

 

 

 

Covered Diagnosis Codes for Procedure Codes 58353, 58356, and 58563

N92.0

N92.1

N92.4

 

 

 

 


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 co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.