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Medical Policy: 04.01.07
Original Effective Date: February 1999
Reviewed: September 2011
Revised: May 2006
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Transcatheter uterine artery embolization, recognized as a treatment for acute pelvic hemorrhage, has been investigated in the management of non-acute uterine hemorrhage due to leiomyomas. Uterine artery embolization is an interventional radiological procedure which uses angiographic techniques. Pelvic arteriography is performed by means of the right femoral approach. The procedure is performed under conscious sedation. The technology presumably reduces fibroids by obstructing the rich blood supply.
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Prior Approval:
Not applicable
However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.
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Policy:
Transcatheter uterine artery embolization may be considered medically necessary for the treatment of symptomatic uterine fibroids.
Repeat procedures to treat persistent symptoms of uterine fibroids after an initial uterine artery embolization would be considered investigational.
The available evidence suggests that the net health outcome after one-time UAE for uterine fibroids is reasonable compared to surgery, especially for women who do not desire to maintain their fertility. There are few studies on long-term health outcomes after UAE; one series suggests that benefits are maintained for a median of 7 years and data from one RCT show similar outcomes to hysterectomy after 5 years with approximately 28% of the women receiving a secondary hysterectomy after UAE. Reviews of fertility and pregnancy outcomes after UAE suggest that successful pregnancy is possible but that there are higher rates of miscarriage and post-partum hemorrhage compared to women with intramural fibroids and higher rates of preterm delivery compared to women whose fibroids had been treated by myomectomy. There is insufficient evidence on health outcomes associated with repeat UAE, and therefore it is considered investigational.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 37210 Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure
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Selected References:
- Spies, JB, Ascher, SA, Roth, A.R., Kim, J., Levy, E.B., Gomez-Jorge, J. Uterine artery embolization for leiomyomata. Obstetrics and Gynecology 2001; 98; 1:29-34.
- McLucas, B, Adler, L. Uterine fibroid embolization compared with myomectomy. International Journal of Gynecology and Obstetrics 2001; 74:297-299.
- Walker, WJ, Pelage, JP, Sutton, C. Fibroid Embolization. Clinical Radiology 2002; 57:325-331.
- Spies, JB, Cooper JM, Worthington-Kirsch R et al. Outcome of Uterine Embolization and Hysterectomy for Leiomyomas: results of a Multi-Center Study. Obstet Gynecol Surv. 2004 Dec;59(12):819-820.
- Hovsepian DM, Siskin GP, Bonn J et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol. 2004 Jun;15(6):535-41.
- Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Uterine Artery Embolization. Obstet Gynecol. 2004 Feb;103(2):403-4.
- Edwards RD, Moss JG, Lumsden MA, Wu O, Murray LS, Twaddle S, Murray GD. Committee of the Randomized Trial of Embolization versus Surgical Treatment for Fibroids. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. New England Journal of Medicine. 2007 Jan 25; 356(4):360-70.
- Ambat S, Mittal S, Srivastava DN et al. Uterine artery embolization versus laparoscopic occlusion of uterine vessels for management of symptomatic uterine fibroids. Int J Gynecol Obstet 2009; 105(2):162-5.
- van der Kooij SM, Hehenkamp WJ, Volkers NA et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol 2010; 203(2):105.e1-13.
- Ruuskanen A, Hippelainen M, Sipola P et al. Uterine artery embolisation versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomized prospective clinical trial. Eur Radiol 2010; 20(10):2524-32.
- Stokes LS, Wallace MJ, Godwin RB et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. J Vasc Interv Radiol 2010; 21(8):1153-63.
- Burke CT, Funaki BS, Ray CE et al. ACR appropriateness criteria® on treatment of uterine leiomyomas. J Am Coll Radio 2011;8(4):228-34.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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