CurrentColorado Rocky Mountain Health PlansPolicy CS002.AG

Abnormal Uterine Bleeding and Uterine Fibroids – Community Plan Medical Policyopen_in_new

Commercial Community Plan medical policy describing coverage positions and medical necessity statements for treatments of abnormal uterine bleeding (AUB) and uterine fibroids including endometrial ablation, levonorgestrel-releasing IUDs (LNG-IUD), uterine artery embolization (UAE/UFE), and magnetic resonance-guided focused ultrasound (MRgFUS), plus associated coding lists and evidence summary. Applies to Colorado Rocky Mountain Health Plans Community Plan except for listed excluded states with state-specific policies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAbnormal Uterine Bleeding and Uterine Fibroids – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS002.AG

Change TypeSupporting information and template updates

Effective DateNov 1, 2025

Next Review Date

Key ActionDocument and verify adherence to referenced InterQual procedural criteria when requesting coverage for endometrial ablation and uterine artery embolization.

SourceLink

POLICY UPDATE CHANGES

Template update removed content/language pertaining to the state of Louisiana.

Clinical evidence and references sections were updated to reflect current information.

4Primary procedures/therapies discussed

9J/HCPCS and CPT codes listed

3Not medically necessary positions

LimitedEvidence strength for MRgFUS

>80%NPVR success threshold

Coverage Summary

Policy CS002.AG addresses treatment options for Abnormal Uterine Bleeding (AUB) and uterine fibroids. Effective date: November 1, 2025. The policy applies to UnitedHealthcare Commercial Community Plan members (with listed state-specific exceptions) and provides coverage positions and medical necessity statements for conservative and procedural therapies.

Primary therapies reviewed include endometrial ablation, levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE/UFE), and magnetic resonance-guided focused ultrasound (MRgFUS / HIFU), with associated CPT and J/HCPCS codes listed for reference.

Coverage stance is mixed: endometrial ablation and LNG-IUDs are described as proven and medically necessary for specified indications (premenopausal AUB and menorrhagia, respectively); UAE is covered for symptomatic fibroids but not for fertility preservation; MRgFUS/MR-HIFU is considered unproven and not medically necessary for treating fibroids due to insufficient evidence. (See policy history for recent non‑material template and evidence updates.)

Thresholds

NPVR success threshold> 80%

Fibroid volume inclusion< 300 cm3

ExAblate historical uterine size limituterine size less than 24 weeks

NICE LNG-IUS size guidancefibroids < 3 cm (LNG-IUS as first treatment for HMB)

Medical-Necessity Criteria

Endometrial Ablation

Endometrial ablation is proven and medically necessary for treating abnormal uterine bleeding in premenopausal individuals. For medical necessity clinical coverage criteria, refer to the InterQual ® CP: Procedures, Hysteroscopy, Operative.

InterQual ® CP: Procedures, Hysteroscopy, Operative — click here to view the InterQual ® criteria.

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

Levonorgestrel-releasing intrauterine devices (LNG-IUD) (e.g., Mirena ®, Skyla ®, Liletta ®, or Kyleena ™) are proven and medically necessary for treating menorrhagia.

Refer to the U.S. Food and Drug Administration (FDA) section for additional information.

Uterine Artery Embolization (UAE / UFE)

Uterine artery embolization (UAE) is proven and medically necessary for treating symptomatic uterine fibroids, postpartum or post hysterectomy bleeding, or uterine arteriovenous malformation (AVM). For medical necessity clinical coverage criteria, refer to the InterQual ® CP: Procedures, Uterine Artery Embolization (UAE).

Evidence, Guidelines, and Clinical Context

Guideline summaries: NICE recommends LNG-IUS as first-line treatment for heavy menstrual bleeding in women with no identified pathology or < 3 cm fibroids and lists UAE and MRgFUS/US‑HIFU as options used with special arrangements for governance, consent, audit/research, clinician training, and careful patient selection in specialized centers. NICE also advises counseling that symptoms may not be fully relieved and effects on fertility are uncertain.

ACOG recommends LNG-IUD may be considered for AUB/bleeding control but notes insufficient evidence for other fibroid symptoms. ACOG endorses UAE as an option for uterine preservation but advises counseling on limited reproductive outcome data and recommends endometrial sampling prior to UFE; ACOG further cautions on morcellation and advises evaluation and shared decision-making regarding dissemination risk.

AAGL position: embolic and ablative therapies (including UAE, RFA, MRgFUS) are not appropriate for submucous myomas in patients with current infertility or desire for future fertility (consensus/expert opinion).

FDA and device guidance: the ExAblate MRgFUS system has PMA indications for uterine fibroid ablation with prior uterine size limitation (< 24 weeks) and labeling changes removed completed‑childbearing restriction in 2015; separately, the FDA issued safety communications discouraging routine use of laparoscopic power morcellators because of risk of disseminating occult malignancy and contraindicating morcellation when malignancy is known or suspected.

Key evidence points: systematic reviews and comparative analyses show LNG-IUD is superior to many medical therapies for heavy menstrual bleeding and is effective as a first-line non-surgical therapy; AHRQ and multiple reviews support UAE as effective for shrinking fibroids and improving bleeding/QOL but evidence is insufficient or mixed regarding preservation of fertility and pregnancy outcomes.

For MRgFUS / HIFU and related ablative therapies: evidence quality is limited and variable—meta-analyses indicate MR‑HIFU achieves lower NPVR than US‑HIFU (example pooled NPVR ~59% vs ~81%; NPVR > 80% considered successful), MRgFUS may reduce fibroid volume but shows less symptom improvement and higher reintervention versus UAE in some randomized/comparative data, and pooled fibroid volume reductions at 6 months favor RFA (≈70%) over UAE (≈54%) and FUS (≈32%) in some reviews. Overall guideline and evidence assessments recommend cautious use, specialized centers, and further high-quality trials.

Coding

Uterine Fibroids / Procedure CPT (reference list)CPT

0071T	Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue.
0072T	Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue.
37243	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.
58563	Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation).

Levonorgestrel-Releasing Intrauterine Device J-codes and supplyHCPCS

J7296	Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg.
J7297	Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg.
J7298	Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg.
J7301	Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg.
J7306	Levonorgestrel (contraceptive) implant system, including implants and supplies.
S4981	Insertion of levonorgestrel-releasing intrauterine system.

Device approvals / informational (no billing codes listed in this part)mixed

No codes listed

Provider Actions & Prior Authorization

Documentation Required

InterQual criteria required for procedural coverage

Medical necessity determinations for endometrial ablation and uterine artery embolization require documentation that the patient meets the referenced InterQual procedural criteria.

Affected CPT codes: 58563, 37243
Document adherence to InterQual CP: Procedures, Hysteroscopy, Operative (for endometrial ablation) and InterQual CP: Procedures, Uterine Artery Embolization (for UAE/UFE)

Documentation Required

Endometrial biopsy recommendation prior to UAE

An endometrial biopsy is recommended prior to uterine artery embolization (UFE/UAE) to help rule out malignancy or hyperplasia; documentation of the biopsy or other endometrial tissue sampling and results may be required.

Definitions

Abnormal uterine bleeding (AUB): In childbearing-age individuals, any change in menstrual frequency or duration, amount of flow, or bleeding between cycles. In postmenopausal individuals, vaginal bleeding 12+ months after cessation of menstruation or unpredictable bleeding while on hormone therapy for ≥12 months. (Policy definition.)

Menorrhagia: Bleeding that occurs at normal intervals but with heavy flow or duration of more than 7 days. (Policy definition.)

NPVR (Nonperfused Volume Ratio): A parameter associated with clinical success in HIFU treatments; an NPVR of > 80% is considered successful. The policy cites pooled NPVR results and notes NPVR thresholds relate to reintervention rates.

MRgFUS / MR-HIFU: Magnetic resonance-guided focused ultrasound (also called magnetic resonance-guided high-intensity focused ultrasound) — a noninvasive thermal ablation technique that uses real-time MR guidance to focus ultrasound beams to thermally coagulate fibroid tissue while sparing normal tissue.

UAE (Uterine Artery Embolization): Endovascular occlusion of the uterine arteries by injection of embolic particles to block blood supply to fibroids, causing them to shrink.

Selected Evidence Metrics

Select numeric evidence metrics

NPVR pooled result (MR-HIFU vs US-HIFU)MR-HIFU NPVR 58.92%; US-HIFU NPVR 81.07%

Fibroid volume reduction at 6 months (pooled) - RFA70%

Fibroid volume reduction at 6 months (pooled) - UAE54%

Fibroid volume reduction at 6 months (pooled) - FUS32%

Evidence-strength note for MRgFUSLimited and low-quality evidence; inconsistent outcomes and higher reintervention vs UAE in some studies

Revision History

11/01/2025Supporting Information updated

Supporting Information updated: Clinical Evidence and References sections updated to reflect current information.

04/01/2026Template Update; archived previous policyLatest

Template update removed content/language pertaining to the state of Louisiana and archived previous policy version CS002.AF.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAbnormal Uterine Bleeding and Uterine Fibroids – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS002.AG

Change TypeSupporting information and template updates

Effective DateNov 1, 2025

Next Review Date

Key ActionDocument and verify adherence to referenced InterQual procedural criteria when requesting coverage for endometrial ablation and uterine artery embolization.

SourceLink

On This Page

MEDICALLY NECESSARY (any)

UAE for symptomatic uterine fibroids with clinically documented fibroids and fibroid-related symptoms when a minimally invasive alternative to hysterectomy is appropriate and the member has been evaluated to exclude malignancy or endometrial hyperplasia (for example, with endometrial biopsy as recommended).
UAE for postpartum or post-hysterectomy bleeding when clinically indicated and conservative measures have failed or are not appropriate.
UAE for uterine arteriovenous malformation (AVM) when embolization is indicated to control bleeding or hemodynamic instability.

NOT MEDICALLY NECESSARY (any)

UAE for the purpose of preserving childbearing potential in individuals with symptomatic uterine fibroids — considered unproven and not medically necessary due to insufficient evidence of efficacy.

InterQual ® CP: Procedures, Uterine Artery Embolization (UAE) — click here to view the InterQual ® criteria.

MRgFUS / HIFU

Magnetic resonance-guided focused ultrasound ablation (MRgFUS) is unproven and not medically necessary for treating uterine fibroids due to insufficient evidence of efficacy.

MRgFUS / HIFU is considered unproven and not medically necessary for treatment of uterine fibroids.

Surface evidence

LNG-IUD evidence summaryMultiple Cochrane reviews and RCTs show LNG-IUS superior to medical therapy for heavy menstrual bleeding; recommended as first-line for certain patients

UAE evidence summaryAHRQ and systematic reviews: effective for shrinking fibroids and improving bleeding/QOL; evidence limited for fertility preservation

MRgFUS evidence summaryMultiple reviews (ECRI, Hayes) indicate low-quality and limited evidence; considered unproven/not medically necessary

NPVR metric (HIFU)NPVR >80% considered successful; MR-HIFU pooled NPVR 58.92% vs US-HIFU 81.07%

Fibroid volume reduction at 6 monthsPooled reductions: RFA 70%, UAE 54%, FUS 32%

NICE HIFU governance guidanceUse MRgFUS/US-HIFU only with special arrangements for governance, consent, audit/research, clinician training, and patient selection

ExAblate device indicationPMA for ablation in women with uterine size <24 weeks; 2015 labeling removed completed-childbearing restriction

Record date and results of endometrial biopsy or sampling

Include any imaging or clinical rationale if biopsy not performed

Document shared decision-making and indication for UAE

Documentation Required

Preoperative evaluation before morcellation

Before morcellation, evaluate and document risk of uterine malignancy using imaging, cervical cancer screening, and endometrial tissue sampling; document shared decision-making and informed consent about the risks of disseminating occult malignancy.

Preoperative risk stratification and imaging results
Cervical cancer screening status
Endometrial sampling results (biopsy/pathology) or reason for omission
Documented informed consent describing risk of dissemination with morcellation and alternatives

Prior Authorization

Special arrangements and patient selection documentation for MRgFUS/HIFU

For MRgFUS or ultrasound-guided HIFU, procedures should be performed only in specialized centers with appropriate governance and clinician training; prior authorization may require documentation of center capability, informed consent about limited efficacy and risks, and plans for audit/research as recommended by NICE.

Procedure performed in a specialized center with documented multidisciplinary team involvement
Document clinician training and credentialing for MRgFUS/HIFU
Document informed consent covering limited efficacy, potential skin burns, uncertain effects on fertility, and possibility of reintervention
Plan for clinical governance, audit, and outcome reporting per NICE recommendations

Documentation Required

Counseling regarding fertility and reproductive outcomes

Counsel patients and document discussions that UAE and ablative therapies have limited or uncertain data regarding reproductive outcomes; record patient's reproductive goals and that counseling occurred per AAGL/ACOG guidance.

Discuss limited evidence on fertility preservation after UAE and potential risks (e.g., altered pregnancy rates, placenta previa, PPH, miscarriage estimates)
Document patient's desire for future fertility and how it affected treatment choice
Record that alternatives and potential need for future interventions were discussed and that shared decision-making occurred

Billing Rule

Policy use guidance

This policy is interpretive guidance for UnitedHealthcare standard benefit plans; verify federal, state, and contractual coverage requirements and applicable third-party tools when determining coverage and billing.

Verify applicable plan, federal, and state requirements which govern coverage decisions
Use InterQual criteria as applicable to support medical necessity determinations
Check for state-specific policy exceptions before applying this policy