Anthem Blue Cross Connecticut Commercial Clinical Policy

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



laparoscopic or transcervical radiofrequency ablation for symptomatic uterine fibroids

Indications

(752888) Is uterine preservation desired by the patient? 
(752889) Are the fibroids less than 10 cm in any diameter? 
(752890) Does the patient's uterine size not exceed 16 weeks' gestation? 

all other laparoscopic or percutaneous ablation techniques with imaging guidance for uterine fibroids

Notes: These procedures are considered investigational and not medically necessary.


Contraindications

(752891) Does the procedure involve lasers, bipolar electrodes, interstitial thermotherapy, cryotherapy or any other technique beyond radiofrequency ablation? 
Effective Date

12/28/2023

Last Reviewed

08/10/2023

Original Document

  Reference



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

Position Statement

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.