Anthem Blue Cross Connecticut CG-SURG-28 Transcatheter Uterine Artery Embolization Form

This document addresses the use of transcatheter uterine artery embolization (UAE) as a treatment for fibroid tumors. UAE is a pelvic angiographic procedure used to decrease the symptoms of heavy bleeding and pelvic pain associated with fibroid tumors. Using hemostatic particles, selected vasculature providing the blood supply to the fibroids are occluded. When the blood supply is occluded, the fibroids decrease in size, thereby reducing the symptoms.

Transcatheter UAE has also been used for treatment of other acute pelvic hemorrhagic conditions such as uterine hemorrhage and ectopic pregnancy. Transcatheter uterine artery embolization is a technique performed by an interventional radiologist.

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

• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications

Clinical Indications

Medically Necessary:

1. Transcatheter uterine artery embolization is considered medically necessary as a treatment of uterine fibroids when any of the following criteria are met:
   1. Excessive uterine bleeding; or
   2. Pelvic discomfort caused by uterine fibroids (for example, acute severe pain, chronic lower abdominal pain, low back pressure, or bladder pressure with urinary frequency not due to urinary tract infection).
2. Transcatheter uterine artery embolization is considered medically necessary in certain situations as a technique to control acute pelvic hemorrhagic conditions from something other than uterine fibroids, such as obstetric hemorrhage or ectopic pregnancy.

Not Medically Necessary:

1. Transcatheter uterine artery embolization is considered not medically necessary when a criterion above has not been met.
2. Repeat transcatheter embolization of uterine arteries to treat persistent symptoms of uterine fibroids after an initial uterine artery embolization is considered not medically necessary.