Anthem Blue Cross Connecticut SURG.00077 Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques Form

This document addresses laparoscopic and percutaneous ablative techniques for the treatment of symptomatic uterine fibroids, including radiofrequency ablation using a transcervical approach. Uterine fibroids, also referred to as leiomyomas, is a common condition that affects women in their reproductive years; symptoms include excessive menstrual bleeding and pelvic pain.

Note: Please see the following related documents for additional information:

• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• CG-SURG-28 Transcatheter Uterine Artery Embolization

Medically Necessary

The use of laparoscopic or transcervical radiofrequency ablation as a treatment for symptomatic uterine fibroids (e.g. excessive uterine bleeding or pelvic discomfort caused by uterine fibroids) is considered medically necessary when all of the following criteria are met:

1. Uterine preservation is desired; and
2. Fibroids are less than 10 cm in any diameter; and
3. Uterine size does not exceed 16 weeks’ gestation.

Not Medically Necessary:

The use of laparoscopic or transcervical radiofrequency ablation as a treatment for uterine fibroids is considered not medically necessary for individuals who do not meet the above criteria.

Investigational and Not Medically Necessary:

The use of all other laparoscopic or percutaneous ablation techniques in combination with imaging guidance as a treatment of uterine fibroids is considered investigational and not medically necessary, including but not limited to lasers, bipolar electrodes, interstitial thermotherapy and cryotherapy.