DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Percutaneous, and Transcervical Techniques for the Uterine Fibroids & Hysterectomies

Defines medical necessity and coverage for radiofrequency ablation (RFA) via laparoscopic (Acessa) and transcervical (Sonata) approaches for symptomatic uterine fibroids, states coverage stance for other myolysis techniques, and documents Rhode Island statutory hysterectomy coverage amendments. Applies to Medicare Advantage and Commercial products of the payer.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPercutaneous, and Transcervical Techniques for the Uterine Fibroids & Hysterectomies

Policy CodePolicy N/A

Change TypeMaterial changes: adds RFA coverage criteria; clarifies noncoverage for non‑RFA myolysis; documents state law hysterectomy coverage.

Effective Date08|01|2026

Next Review DateN/A

Key ActionObtain prior authorization for RFA procedures for Medicare Advantage plans and verify benefits/authorization for all members.

SourceLink

POLICY UPDATE CHANGES

Laparoscopic or transcervical RFA (Acessa, Sonata) is considered medically necessary for symptomatic uterine fibroids when specified criteria are met.

Other laparoscopic, transcervical, or percutaneous myolysis techniques (laser, bipolar needles, cryomyolysis, MRI-guided laser) are considered not covered / not medically necessary.

State law amendments require coverage for hysterectomy, myomectomy, laparoscopic removal of uterine fibroids, uterine artery embolization, intraoperative ultrasound guidance and radiofrequency ablation effective Jan 1, 2023.

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products.

18+min age

≤10 cm

Coverage Criteria for Myolysis and Hysterectomy

Medically Necessary: Laparoscopic or Transcervical RFA

Covered when ALL of the following are met:

RFA coverage criteria: Evidence of uterine fibroids demonstrated by ultrasound with size limits by approach: ≤10 cm maximum diameter for laparoscopic RFA (Acessa) OR ≤7 cm maximum diameter for transcervical RFA (Sonata).

Patient selection: Individual desires a uterine‑sparing treatment approach or is ineligible for hysterectomy or other uterine‑sparing alternatives (e.g., laparoscopic myomectomy, uterine artery embolization).

Applies to individuals 18 years and older.

Symptomatic requirement: Individual has experienced at least one symptom directly resulting from the fibroid(s): menorrhagia or other abnormal uterine bleeding that interferes with daily activities or causes anemia; pelvic pain or pressure; urinary symptoms (e.g., frequency, urgency) from bladder compression; gastrointestinal symptoms from bowel compression (e.g., constipation, bloating); or dyspareunia.

Other laparoscopic, transcervical, or percutaneous myolysis techniques — including use of laser, bipolar needles, cryomyolysis, and MRI-guided laser ablation — are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products.

If services are determined to be not medically necessary or are non-covered benefits under the member's subscriber agreement or employer agreement, those services are excluded from coverage and benefits are subject to the terms of the member's plan.

For non‑RFA myolysis techniques (for example, laser, bipolar needles, cryomyolysis, and MRI‑guided laser ablation), the evidence is insufficient to determine the effects on health outcomes; therefore these approaches are considered not covered for Medicare Advantage and not medically necessary for Commercial Products.

If a service is determined to be not medically necessary (or is a medically necessary service that is a non‑covered benefit under the member's plan), the provider may not bill the member for the service unless the member was informed in advance and provided written agreement to self‑pay.

Coding and Procedure Limits

Covered CPT CodesCPTCovered

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

Unlisted Procedures (use when no CPT exists for other therapies)CPT

58578	Unlisted laparoscopy procedure, uterus
58999	Unlisted procedure, female genital system (nonobstetrical)

Hysterectomy CPT Codes (covered; prior auth not required)CPTCovered

58140-58294	Range of CPT codes for hysterectomy procedures
58541-58554	Range of CPT codes for hysterectomy procedures
58570-58575	Range of CPT codes for hysterectomy procedures

Maximum fibroid diameter by approach — size thresholds for RFA

Laparoscopic RFA (Acessa) maximum fibroid diameter≤ 10 cm

Transcervical RFA (Sonata) maximum fibroid diameter≤ 7 cm

Applies to patientsIndividuals 18 years and older

Provider Actions, Authorization, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. Verify whether prior authorization is required for the member's specific plan before scheduling or performing the procedure.

Prior authorization required for Medicare Advantage Plans; recommended for Commercial Products
Confirm prior authorization requirements and obtain approval when applicable prior to service

Note

Verify Benefits and Eligibility

Check member-specific benefits, eligibility, and any plan exclusions or prior authorization status with the payer before providing services. Coverage is determined by the member's subscriber agreement or employer contract and may differ from this policy.

Contact the provider call center for member-specific benefits and eligibility

Background and Clinical Context

Uterine fibroids (leiomyomas) are common in reproductive‑aged individuals and can cause symptoms such as menorrhagia or abnormal uterine bleeding, pelvic pressure or pain, urinary frequency from bladder compression, gastrointestinal symptoms from bowel compression, and dyspareunia. Standard surgical options include hysterectomy and myomectomy, which may eliminate fertility; minimally invasive, uterine‑sparing treatments (including radiofrequency ablation) aim to reduce fibroid volume and relieve symptoms while preserving the uterus.

Definitions

Myolysis / Radiofrequency ablation (RFA) — definition and procedural overview

DefinitionMyolysis/Radiofrequency ablation (RFA): a procedure using energy (eg, radiofrequency) to create focal necrosis within uterine fibroids to reduce volume and relieve symptoms.

ApproachesPerformed laparoscopically (eg, Acessa) or transcervically (eg, Sonata) with intraoperative imaging guidance (ultrasound) to locate fibroids and guide the probe.

Procedure summaryUltrasound is used to determine fibroid size/location, guide probe placement, and monitor energy delivery to ablate fibroid tissue without repetitive serosal needle passes used in older techniques.

Contrast with other myolysis techniquesIncludes other myolysis methods (laser, bipolar electrodes, cryomyolysis, MRI-guided laser ablation) historically studied, but the policy distinguishes RFA as the covered technique while other methods are considered not covered or not medically necessary depending on product.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPercutaneous, and Transcervical Techniques for the Uterine Fibroids & Hysterectomies

Policy CodePolicy N/A

Change TypeMaterial changes: adds RFA coverage criteria; clarifies noncoverage for non‑RFA myolysis; documents state law hysterectomy coverage.

Effective Date08|01|2026

Next Review DateN/A

Key ActionObtain prior authorization for RFA procedures for Medicare Advantage plans and verify benefits/authorization for all members.

SourceLink

On This Page

Denial Risk

Member Liability and Denial Risk

Services that are not medically necessary or are non-covered under the member's plan may be denied. Providers should inform members in advance and obtain written agreement if the member elects to proceed and accept financial responsibility.

If a service is denied as not medically necessary or is a non-covered benefit, the provider may not charge the member unless the member agreed in writing in advance to pay
Review participation agreements for applicable billing provisions and potential member liability

Documentation Required

Coding and Documentation Guidance

Document the clinical indication and medical necessity thoroughly and use the appropriate CPT or unlisted procedure codes when billing. Include supporting imaging, symptom description, prior conservative treatments or reasons for ineligibility for alternative uterine-sparing procedures, and confirmation that the patient desires uterine-sparing treatment when applicable.

When criteria are met, use CPT 58580 for transcervical RFA (Sonata)
When criteria are met, use CPT 58674 for laparoscopic RFA (Acessa)
Use unlisted codes where no specific CPT exists: 58578, 58999
Include operative report, intraoperative ultrasound documentation, imaging showing fibroid size, symptom history, and prior treatment information in the medical record