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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-56000-26

Original Effective Date: 04/17/00

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Occlusion of Uterine Arteries Using Transcatheter Embolization

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Transcatheter uterine artery embolization (UAE) is a minimally invasive technique that involves the injection of small particles into the uterine arteries to block the blood supply to the uterus and uterine fibroids.

Transcatheter uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE) is a minimally invasive endovascular procedure. UAE involves the use of angiographic guidance for selective catherization of the uterine arteries with injection of an embolization material to block the arteries that provide blood flow, causing the fibroid to shrink. Transcatheter uterine artery embolization has been used to treat postpartum hemorrhage.

Laparoscopic uterine artery occlusion has been investigated as an alternative to UAE. With laparoscopic uterine artery occlusion, multiple laparoscopic laser punctures of the uterine fibroid are performed in an effort to devascularize the fibroid and induce atrophy.

Several embolization devices are approved by the Food and Drug Administration (FDA) (e.g., Embosphere┬« Microspheres (Merit Medical, formerly BioSphere Medical), Contour┬« PVA (Boston Scientific), Contour SE™ (Boston Scientific), Polyvinyl Alcohol Foam Embolization Particles (Cook Inc.)).

POSITION STATEMENT:

Transcatheter embolization of uterine arteries meets the definition of medical necessity for the treatment of:

One repeat transcatheter embolization of uterine arteries to treat persistent symptoms (e.g., bleeding, pain) of uterine fibroids after an initial uterine artery embolization meets the definition of medical necessity.

Transcatheter embolization of uterine arteries for the management of all other indications is considered experimental or investigational. The evidence is insufficient to determine the effects of the technology on health outcomes.

Laparoscopic occlusion of the uterine arteries using bipolar coagulation is considered experimental or investigational. The evidence is insufficient to support conclusions regarding effects on health outcomes.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code to report transcatheter embolization of uterine arteries.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Atrophy: a wasting away; a diminution in the size of a cell, tissue, organ, or part.

Dysmenorrhea: painful menstruation.

Leiomyomata: leiomyomata of the uterus usually occurring in the third and fourth decades of life, characterized by multiple, firm, round, sharply circumscribed, unencapsulated, gray to white tumors that show a whorled pattern on cut section. The majority are within the myometrium of the corpus of the uterus, but they may also occur in the cervix, usually in its posterior wall.

Menorrhagia: menstruation with an excessive flow but at regular intervals and of usual duration.

Myomectomy: surgical excision of a uterine myoma (leiomyoma).

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report transcatheter uterine artery embolization:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Uterine fibroid embolization (UFE)
Transcatheter embolization

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ). U.S. Department of Health and Human Services. Evidence Report/Technology Assessment: Number 34. “Management of Uterine Fibroids”; 02/01.
  2. Agency for Healthcare Research and Quality (AHRQ). U.S. Department of Health and Human Services Evidence Report/Technology Assessment Number 154. Management of Uterine Fibroids: An Update of the Evidence, 07/07.
  3. American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 293. Uterine Artery Embolization, 2004.
  4. American College of Obstetricians and Gynecologists (ACOG) News Release. “Uterine Artery Embolization: Evidence Increasing on its Success in Treating Fibroids; (06/01).
  5. American College of Obstetricians and Gynecologists (ACOG) News Release. ACOG Issues Opinion on Uterine Artery Embolization for Treatment of Fibroids, 01/30/04.
  6. American College of Obstetricians and Gynecologists (ACOG) Uterine fibroids, 03/09.
  7. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstetrics and Gynecology 2008; 96: 387-399.
  8. American Medical Association (AMA) Current Procedural Terminology (CPT), 2009.
  9. Andrews RT, Spies JB, Sacks D et al. Standards of Practice patient care and uterine artery embolization for leiomyomata, Journal of Vascular and Interventional Radiology, 2004.
  10. Beinfeld MT, Bosch JL, Isaacson KB et al. Cost-effectiveness of uterine artery embolization and hysterectomy for uterine fibroids1. Radiology 2004; 230(1): 207-213.
  11. Blue Cross Blue Shield Association Occlusion of Uterine Arteries Using Transcatheter Embolization or Laparoscopic Occlusion to Treat Uterine Fibroids 4.01.11, 08/16.
  12. Blue Cross Blue Shield Association Technology Evaluation Center (TEC)-Uterine Artery Embolization for Treatment of Symptomatic Uterine Fibroids, 08/02.
  13. Dariushnia SR, Nikolic B, Stokes LS et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. Journal of Vascular and Interventional Radiology 2014;25(11):1737-1747.
  14. de Bruijn, Ankum WM, Reekers JA et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. American Journal of Obstetrics and Gynecology 2016;215(6):745.e1-745.e12.
  15. Edwards RG, Moss JG, Lumsden MA et al (The Rest Investigators). Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids. The New England Journal of Medicine 2007; 356(4): 360-370.
  16. Evans P, Brunsell S. Uterine Fibroid Tumors: Diagnosis and Treatment. American Family Physicians 2007; 75(10): 1503-1508.
  17. Gupta JK, Sinha A, Lumsden MA et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database of Systematic Reviews 2014; 26(12): CD005073.
  18. Goodwin SC, Spies JB, Worthington-Kirsch R et al. Uterine artery embolization for treatment of leiomyomata: long-term outcomes form the FIBROID Registry. Obstetric & Gynecology 2008; 111(1): 22-33.
  19. Hald K, Klow NE, Qvigstad E et al. Laproscopic occlusion compared with embolization of uterine vessels: a randomized controlled trial. Obstetrics and Gynecology 2007; 109(1): 20-27.
  20. Hehenkamp WJK, Volkers NA, Birnie E et al. Symptomatic uterine fibroids: Treatment with uterine artery embolization or hysterectomy-Results from the randomized clinical embolisation versus hysterectomy (EMMY) trial1. Radiology 2008; 246(3): 823-831.
  21. Hirst A, Dutton S, wu O, et al. A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technology Assessment 2008; 12(5): 1-264.
  22. Kim TH, Lee HH, Kim JM et al. Uterine artery embolization for primary postpartum hemorrhage. Iran Journal of Reproductive Medicine 2013;11(6):511-518.
  23. Levy, E. B., & Spies, J.B. Transcatheter uterine artery embolization for the treatment of symptomatic uterine fibroid tumors. Journal of Women’s Imaging 2000; 2(4): 168-175.
  24. Lichtinger M, Hallson L, Calvo P et al. Laparoscopic uterine artery occlusion for symptomatic leiomyomas. The Journal of the American Association of Gynecologic Laparoscopists 2002 May; 9(2): 191-198.
  25. McLucas B, Reed RA. Repeat uterine artery embolization following poor results. Minimally Invasive Therapy & Allied Technologies 2009;18(2): 82-86.
  26. National Guideline Clearinghouse-Alternative to hysterectomy in the management of leiomyomas, 01/23/09.
  27. Stokes LS, Wallace MJ, Godwin RB et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. Journal of Vascular and International Radiology 2010; 21(8):1153-1163.
  28. Tropeano fAmoroso S, Scambia G. Non-surgical management of uterine fibroids. Human Reproduction Update 2008; 14(3): 259-274.
  29. Van der Kooij SM, Hehenkamp WJ, Vokers NA et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. American Journal of Obstetrics and Gynecology 2010 Aug; 203(2): 105.e1-105.e13.
  30. Vilos GA, Allaire C, Laberge PY et al. The management of uterine leiomyomas. Journal of Obstetrics and Gynaecology Canada 2015;37(2):157-81.
  31. Viswanathan M, Hartmann K, McKoy N et al. Management of uterine fibroids: an update of the evidence. Evidence Report Technology Assessment 2007; (154): 1-122.
  32. Volkers NA, Hehenkamp JK, Birnie E et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years’ outcome from the randomized EMMY trial. American Journal of Obstetrics & Gynecology 2007; 196(6): 519-521.
  33. Wong, G. C. H., & Goodwin, S. C. Uterine artery embolization for uterine fibroids. Applied Radiology, 2001; 30(1): 26-31.
  34. Worthington-Kirsch RL. Uterine Artery Embolization. Endovascular Today 2004; 21-26.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

04/17/00

Medical Coverage Guideline Reformatted.

01/01/02

HCPCS coding changes.

08/15/02

Reviewed. Coverage changed from Investigational to Covered based on medical necessity.

07/15/04

Scheduled review. Delete reference to InterQual Planning Criteria for myomectomy and hysterectomy.

08/15/05

Scheduled review. Added statement considering laparoscopic occlusion with bipolar coagulation investigational added. Revised description section. Updated references.

08/15/06

Scheduled review. Revised the definitions for menorrhagia and myomectomy. Updated references.

01/01/07

HCPCS update. Added 37210.

04/01/07

HCPCS update. Deleted S2250.

07/15/07

Scheduled review; no change in coverage statements; reformatted guideline.

09/15/08

Scheduled review. No change in position statement. Updated references.

10/15/09

Annual review. Maintain position statements. Updated guideline description section. Added “and occlusion of uterine arteries” to guideline subject. Updated references.

01/15/11

Revision; related ICD-10 codes added.

10/15/11

Annual review; maintain position statements. Updated references.

01/01/14

Annual HCPCS coding update; deleted 37210. Revision; Program Exceptions section updated.

05/11/14

Revision: Program Exceptions section updated.

04/15/17

Added treatment of postpartum hemorrhage, one repeat transcatheter embolization of uterine arteries to treat persistent symptoms (e.g., bleeding, pain) of uterine fibroids after an initial uterine artery embolization and transcatheter embolization of uterine arteries for the management of all other indications.

Date Printed: October 20, 2017: 08:40 AM