CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Laparoscopic, Percutaneous, and Transcervical Techniques for the Myolysis of Uterine Fibroids & Hysterectomies

Coverage policy for laparoscopic, percutaneous, and transcervical myolysis techniques (including RFA) and hysterectomy coverage amendments in Rhode Island; applies to Medicare Advantage and Commercial products and governs when procedures are medically necessary and which techniques are not covered.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLaparoscopic, Percutaneous, and Transcervical Techniques for the Myolysis of Uterine Fibroids & Hysterectomies

Policy CodePolicy N/A

Change TypeMaterial additions and clarifications (codes addedsize limits specifiedstate mandate noted)

Effective DateSep 1, 2022

Next Review DateMay 3, 2025

Key ActionObtain prior authorization for RFA procedures (required for Medicare Advantage; recommended for Commercial) and document ultrasound-confirmed fibroid size within specified limits.

SourceLink

POLICY UPDATE CHANGES

New CPT code 58580 (transcervical ablation including intraoperative ultrasound guidance and monitoring, radiofrequency) is listed as medically necessary effective 1/01/2024.

Specific size limits for fibroids eligible for RFA are specified: <10 cm for laparoscopic (Acessa) and <7 cm for transcervical (Sonata).

Rhode Island statutory amendments require coverage for hysterectomy, myomectomy, laparoscopic removal of fibroids, UAE, intraoperative ultrasound guidance and radiofrequency ablation commencing January 1, 2023.

2RFA approaches covered

>=18Minimum age

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Coverage and Medical Necessity Criteria

RFA (laparoscopic or transcervical) Medical Necessity

Covered when ALL of the following are met:

Age: Individual is at least 18 years of age>=18 years

Imaging size limits: Ultrasound evidence of uterine fibroids with size limits: less than 10 cm for laparoscopic RFA (Acessa) OR less than 7 cm for transcervical RFA (Sonata)<10 cm (lap), <7 cm (trans)

Symptom 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 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 (painful or difficult sexual relations)

List of acceptable symptoms provided in policy

Treatment preference 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)

Other laparoscopic, transcervical, or percutaneous myolysis techniques — including methods that use laser energy, bipolar needles, or cryomyolysis — and image-guided ablative approaches such as MRI-guided laser ablation are addressed separately from radiofrequency ablation (RFA). These techniques are not established as medically necessary in this policy and therefore are not covered under the same indication as RFA for symptomatic uterine fibroids.

Use of non‑RFA myolysis techniques (for example, laser, bipolar needle myolysis, cryomyolysis, or MRI‑guided laser ablation) is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products due to insufficient evidence. When such non‑RFA myolysis procedures are performed, providers should bill using the unlisted procedure code 58999 as CPT codes have not been assigned to these services.

Coding and Procedural Codes

Covered CPT CodesCPTCovered

58580	Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency (New code effective 1/01/2024)
58674	Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency

Unlisted / Use when not covered therapies performedCPT

58999

Unlisted procedure, female genital system (nonobstetrical) — use for non-RFA myolysis techniques

Hysterectomy CPT CodesCPTCovered

58140-58294	Hysterectomy CPT codes (range) — covered
58541-58554	Laparoscopic hysterectomy CPT codes (range) — covered
58570-58575	Laparoscopic supracervical or related hysterectomy CPT codes (range) — covered

Maximum fibroid diameter for eligibility — size limits for laparoscopic (Acessa) and transcervical (Sonata) approaches

Laparoscopic RFA (Acessa) maximum fibroid diameterFibroids must be less than 10 cm in diameter

Transcervical RFA (Sonata) maximum fibroid diameterFibroids must be less than 7 cm in diameter

Age threshold linked to size eligibilitySize limits apply when individual is at least 18 years of age (policy requires >=18 years)

Imaging requirement for size determinationUltrasound evidence must document fibroid diameters to confirm they meet the size limits

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. Submit requests to BCBSRI prior authorization per plan procedures. Include relevant clinical documentation (see Documentation callout) to support medical necessity. Failure to obtain prior authorization when required may result in claim denial or delayed payment.

Applies to Medicare Advantage Plans (required) and Commercial Products (recommended)
Include CPT codes 58580, 58674, and when applicable 58999 (unlisted) on the request

Step Therapy

Step Therapy / Sequencing

Step therapy / sequencing: RFA is appropriate when the individual desires a uterine-sparing approach or is ineligible for hysterectomy or other uterine-sparing alternatives. Providers should document prior trials or ineligibility for alternative uterine-sparing treatments when applicable.

Preference for uterine-sparing alternatives (e.g., laparoscopic myomectomy, uterine artery embolization) should be considered before RFA when clinically appropriate

Background and Scope

Uterine fibroids (leiomyomas) are among the most common conditions affecting individuals of reproductive age and can cause heavy menstrual bleeding, pelvic pressure or pain, urinary and gastrointestinal symptoms, and sexual dysfunction. Standard surgical treatments such as hysterectomy and myomectomy provide definitive symptom resolution, but minimally invasive, uterine‑sparing options have been developed to reduce morbidity and preserve the uterus.

This policy specifically addresses myolysis techniques with an emphasis on radiofrequency ablation (RFA) performed laparoscopically or transcervically and establishes when those RFA procedures are considered medically necessary. It also documents the payer stance and coding for hysterectomy procedures in Rhode Island. Hysterectomies are covered services and the listed hysterectomy CPT code ranges do not require prior authorization.

Non‑RFA myolysis techniques (such as laser, bipolar needles, cryomyolysis, and MRI‑guided laser ablation) are excluded from coverage under this policy because the evidence is insufficient to determine their effect on health outcomes; when such non‑RFA services are performed they should be reported with unlisted code 58999. In addition, the policy includes operational coding updates relevant to RFA, including the designation of CPT 58580 for transcervical RFA (effective 1/01/2024) and CPT 58674 for laparoscopic RFA, which are considered medically necessary when the specified clinical criteria are met.

Definitions and Procedural Descriptions

Myolysis / Radiofrequency ablation (RFA) — techniques, mechanisms, and examples (Acessa, Sonata)

Definition of myolysis / RFATechniques that use an energy source (eg, radiofrequency) to create areas of necrosis within uterine fibroids, reducing fibroid volume and symptoms

ApproachesCan be performed laparoscopically (eg, Acessa) or transcervically with intraoperative ultrasound guidance (eg, Sonata)

Mechanism and guidanceUltrasonography is used laparoscopically or transcervically to determine size and location of fibroids, guide the probe, and ensure optimal energy delivery

Contrast with earlier techniquesNewer RFA systems avoid repetitive insertions of needle electrodes used in early probe-based myolysis, reducing risk of serosal injury and adhesions

Non-RFA myolysis examples (not covered)Other myolysis techniques include laser, bipolar needles, cryomyolysis, and MRI-guided laser ablation (these are treated separately in the policy)