CurrentBlue Cross Blue Shield - MassachusettsPolicy 244

Radiofrequency ablation (RFA) for symptomatic uterine fibroids — laparoscopic and transcervical

This policy governs coverage of laparoscopic and transcervical radiofrequency ablation for treatment of symptomatic uterine fibroids for commercial and Medicare members of Blue Cross Blue Shield Massachusetts, specifying medical necessity criteria, prior authorization rules, and coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyRadiofrequency ablation (RFA) for symptomatic uterine fibroids — laparoscopic and transcervical

Policy CodePolicy 244

Change TypeLiterature reviewreferences updated

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization when the procedure is performed inpatient and include imaging confirming fibroid size and documentation of uterine-sparing intent when seeking coverage.

SourceLink

POLICY UPDATE CHANGES

2/2026 – literature review through 12/30/2025; reference added; policy statements unchanged.

18+minimum patient age for coverage

<=10 / <=7 cmmax fibroid diameter (lap / transcerv)

Prior authprecert required (inpatient)

2 codesprimary procedure codes

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Coverage and Medical Necessity Criteria

Medical Necessity Criteria

Covered when ALL of the following are met

Age: Individual is 18 years or older>=18 years

Fibroid size by approach: Evidence of uterine fibroids via ultrasound that are less than 10 cm in diameter for laparoscopic RFA with Acessa OR less than 7 cm in diameter for transcervical RFA with Sonata<=10 cm (laparoscopic) OR <=7 cm (transcervical)

Uterine-sparing intent or ineligibility: Individual desires a uterine-sparing treatment approach or is ineligible for hysterectomy or other uterine-sparing alternatives (e.g., laparoscopic myomectomy, uterine artery embolization)

Symptom requirement: Individual has experienced at least one symptom that is a direct result of the fibroid(s)

Listed symptoms include menorrhagia/other abnormal uterine bleeding that interferes with daily activities or causes anemia; pelvic pain or pressure; lower back pain; urinary symptoms related to bulk compression of the bladder (e.g., frequency, urgency); gastrointestinal symptoms related to bulk compression of the bowel (e.g., constipation, bloating); dyspareunia

Investigational Techniques

Not covered / investigational when ANY of the following alternative techniques are used

Investigational techniques: Other laparoscopic, transcervical, or percutaneous myolysis techniques (for example: laser ablation, bipolar needles, cryomyolysis, and magnetic resonance imaging-guided laser ablation) are considered investigational

These techniques lack sufficient evidence to demonstrate improvement in net health outcome

RFA — patient selection

Covered when ALL of the following are met

Eligibility for RFA: Woman 18 years or older; imaging evidence of uterine fibroids (ultrasound) with diameters less than or equal to device-specific thresholds (<=10 cm for laparoscopic Acessa or <=7 cm for transcervical Sonata); patient desires a uterine-sparing treatment approach or is ineligible for hysterectomy or other uterine-sparing alternatives (e.g., laparoscopic myomectomy, uterine artery embolization); AND patient has at least one symptom directly attributable to the fibroid(s) — menorrhagia or other abnormal uterine bleeding that interferes with daily activities or causes anemia, pelvic pain or pressure, urinary symptoms from bulk effect, gastrointestinal symptoms from bulk effect, or dyspareunia.Device-specific size limits included

Clinical input supports these selection criteria

Individuals older than 45 years with menorrhagia or other abnormal uterine bleeding should undergo endometrial biopsy prior to definitive treatment to rule out endometrial malignancy and to assess for risk of uterine leiomyosarcoma. Alternative causes of pelvic pain (for example, endometritis or active pelvic inflammatory disease) should also be excluded prior to proceeding with radiofrequency ablation or other uterine-sparing interventions.

Several alternative myolysis techniques — including laser ablation, bipolar needle myolysis, cryomyolysis, and magnetic resonance imaging (MRI)–guided laser ablation — have limited and low-quality evidence. Available data for laser and bipolar needle approaches are largely case series from older literature, cryomyolysis evidence comes from small case series (sample sizes ≤20), and MRI-guided laser ablation is supported by a single nonrandomized study with historical controls. Because randomized controlled trial data and longer-term comparative outcomes are lacking, these techniques are not supported by robust randomized evidence to establish improved net health outcomes.

Use of laser or bipolar needle myolysis, cryomyolysis, and MRI-guided laser ablation for treatment of symptomatic uterine fibroids is considered experimental/investigational and not medically necessary due to insufficient high-quality evidence demonstrating safety and efficacy compared with established alternatives.

For symptomatic uterine fibroids, the body of evidence for laser or bipolar needle techniques, cryomyolysis, and MRI-guided laser ablation is insufficient to conclude an improvement in net health outcome. Case series and single nonrandomized studies dominate the literature, limiting confidence in benefit, durability, and comparative effectiveness versus standard uterine-sparing options.

Billing and Coding Guidance

Covered CPT CodesCPTCovered

58674	Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency
58580	Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency

Medically necessary ICD-10 codes (when submitted with above CPTs)ICD-10

No codes listed

Covered/affected codesmixed

No codes listed

Medically necessary ICD-10 codes (when submitted with above CPTs)ICD-10

D25.0	Submucous leiomyoma of the uterus
D25.1	Intramural leiomyoma of the uterus
D25.9	Leiomyoma of the uterus, unspecified
N93.8	Other specified abnormal uterine and vaginal bleeding
N93.9	Abnormal uterine and vaginal bleeding, unspecified
N94.10	Unspecified dyspareunia
N94.11	Superficial (introital) dyspareunia
N94.12	Deep dyspareunia
N94.19	Other specified dyspareunia
R10.20	Pelvic and perineal pain unspecified

1–10 of 12

1/2

Covered/affected codesmixed

No codes listed

Maximum fibroid diameter for RFA by approach

Laparoscopic RFA (approach-level)Maximum individual fibroid diameter ≤ 10 cm for laparoscopic radiofrequency ablation (Acessa) when documented by ultrasound

Transcervical RFA (approach-level)Maximum individual fibroid diameter ≤ 7 cm for transcervical radiofrequency ablation (Sonata) when documented by ultrasound

Age constraintApplicable to individuals 18 years and older as part of eligibility criteria

Maximum fibroid diameter for device-specific RFA

Laparoscopic — Acessa deviceDevice-specific maximum fibroid diameter ≤ 10 cm for laparoscopic Acessa system, documented by ultrasound

Transcervical — Sonata device

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Preauthorization/Precertification is required when the procedure is performed inpatient. Outpatient procedures do not require prior authorization for the listed products (Commercial Managed Care HMO/POS, Commercial PPO and Indemnity, Medicare HMO Blue SM, Medicare PPO Blue SM). Failure to obtain required inpatient precertification may result in denial of coverage.

Inpatient: precertification/preauthorization IS REQUIRED for all products when performed inpatient.
Outpatient: prior authorization is NOT required for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM.

Documentation Required

Prior Authorization and Required Supporting Information

When prior authorization is requested or required, include all documentation that demonstrates policy criteria are met. Supporting information should include: ultrasound imaging showing uterine fibroids with recorded diameters; when ultrasound cannot distinguish fibroids from adenomyosis, provide MRI; documentation that the patient desires a uterine-sparing approach or is ineligible for hysterectomy or other uterine-sparing alternatives (e.g., laparoscopic myomectomy, uterine artery embolization); and clinical notes confirming fibroid-related symptoms (e.g., menorrhagia with impact on activities or causing anemia, pelvic pain/pressure, urinary or gastrointestinal symptoms, dyspareunia). For individuals >45 years with abnormal uterine bleeding, include endometrial biopsy results to rule out malignancy when applicable. For pelvic pain, document exclusion of alternative causes (e.g., endometritis, active pelvic inflammatory disease).

Clinical Background and Context

Uterine fibroids (leiomyomas) are common in reproductive‑aged individuals and may cause menorrhagia/abnormal uterine bleeding, pelvic pressure or pain, and other bulk symptoms that can impair quality of life. Definitive surgical options such as hysterectomy or myomectomy eliminate fibroids but may not preserve fertility or the uterus. Minimally invasive myolysis techniques, including radiofrequency ablation (RFA), aim to reduce fibroid volume and symptoms while preserving the uterus; RFA systems use ultrasonographic guidance and can be delivered either laparoscopically or transcervically depending on fibroid size, number, and location. Evidence for RFA includes cohorts and randomized trials showing short‑term improvements in symptoms and quality of life and faster recovery compared with myomectomy, but longer‑term recurrence and reintervention data are limited.

Definitions and Classification

FIGO leiomyoma subclassification

ScopeFIGO leiomyoma subclassification categorizes fibroid location and relationship to the uterine cavity and serosa (types 0–8 and hybrid) to guide approach selection

Type 0–2Submucosal classifications: Type 0 (pedunculated intracavitary), Type 1 (<50% intramural), Type 2 (≥50% intramural)

Type 3–6Intramural and subserosal relations: Type 3 contacts endometrium; Type 4 entirely intramural; Types 5–6 subserosal with varying intramural components

Type 7–8 and HybridType 7 pedunculated subserosal; Type 8 non‑myometrial locations (e.g., cervical); Hybrid (X–X) denotes both submucosal and subserosal components

Abnormal uterine bleeding

Evaluation — age >45In individuals >45 years with menorrhagia or other abnormal bleeding, an endometrial biopsy is recommended prior to treatment to rule out endometrial malignancy