Endometrial Ablation
Covered when medically necessary for treating abnormal uterine bleeding in premenopausal individuals and applicable clinical criteria are met.
Abnormal uterine bleeding is present in a premenopausal individual.
Medical necessity clinical coverage criteria are met under InterQual® CP: Procedures, Hysteroscopy, Operative.
Refer to the InterQual® criteria.
Levonorgestrel-Releasing Intrauterine Device
Covered when medically necessary for treating menorrhagia.
Treatment with a levonorgestrel-releasing intrauterine device is medically necessary for the stated indication.
Examples include Mirena®, Skyla®, Liletta®, and Kyleena™. Refer to the FDA section for additional information.
Uterine Artery Embolization
Covered when medically necessary for symptomatic uterine fibroids, postpartum or posthysterectomy bleeding, or uterine arteriovenous malformation, and applicable clinical criteria are met.
ONE of the following indications
Symptomatic uterine fibroids.
Posthysterectomy bleeding.
Uterine arteriovenous malformation.
Medical necessity clinical coverage criteria are met under InterQual® CP: Procedures, Uterine Artery Embolization (UAE).
Refer to the InterQual® criteria.
Initial Therapy When Fertility Preservation Is Desired
ACR considers the following equivalent alternatives usually appropriate for initial therapy; in most cases, medical management should be trialed before more invasive therapies.
ALL of the following
The patient is of reproductive age and has uterine fibroids.
The patient is symptomatic with heavy uterine bleeding or bulk symptoms, such as pressure, pain, fullness, bladder symptoms, or bowel symptoms.
The patient desires to preserve fertility.
ONE usually appropriate initial therapy
Initial Therapy When Future Fertility Is Not Desired
ACR considers the following equivalent alternatives usually appropriate for initial therapy; in most cases, medical management should be trialed before more invasive therapies.
ALL of the following
The patient is of reproductive age and has uterine fibroids.
The patient is symptomatic with heavy uterine bleeding or bulk symptoms, such as pressure, pain, fullness, bladder symptoms, or bowel symptoms.
The patient has no desire for future fertility.
ONE usually appropriate initial therapy
Initial Therapy for Fibroids With Concurrent Adenomyosis
ACR considers medical management or UAE usually appropriate for initial therapy; in most cases, medical management should be trialed before more invasive therapy.
ALL of the following
The patient is of reproductive age and has uterine fibroids with concurrent adenomyosis.
The patient is symptomatic with heavy uterine bleeding or bulk symptoms, such as pressure, pain, fullness, bladder symptoms, or bowel symptoms.
The patient has no desire for future fertility.
ONE usually appropriate initial therapy
Initial Therapy for Pedunculated Submucosal Fibroids
ACR considers hysteroscopic myomectomy or medical management usually appropriate for initial therapy; in most cases, medical management should be trialed before more invasive therapy.
ALL of the following
The patient is of reproductive age.
The patient has pedunculated submucosal uterine fibroids.
The fibroids are symptomatic with heavy uterine bleeding.
ONE usually appropriate initial therapy
Hysteroscopic myomectomy.
Next-Step Therapy After Negative Biopsy in Postmenopause
ACR considers hysterectomy usually appropriate as the next step in this clinical scenario.
ALL of the following
The patient is postmenopausal.
The patient has uterine fibroids.
The patient is symptomatic with heavy uterine bleeding or bulk symptoms, such as pressure, pain, fullness, bladder symptoms, or bowel symptoms.
Endometrial biopsy is negative.
Hysterectomy is selected as the next-step therapy.
Initial Therapy for Fibroid-Related Reproductive Dysfunction
ACR considers hysteroscopic myomectomy or laparoscopic or open myomectomy usually appropriate initial therapy; these are equivalent alternatives, and the panel did not agree that medical management should be recommended for this scenario.
ALL of the following
The patient is of reproductive age.
The patient has uterine fibroids.
The patient desires pregnancy.
The patient is experiencing reproductive dysfunction.
ONE usually appropriate initial therapy
Hysteroscopic myomectomy.
Medical Management of Abnormal Uterine Bleeding
ACOG recommendations for medical management of abnormal uterine bleeding include the following options and considerations.
Medical management options or considerations
Levonorgestrel-releasing intrauterine device may be considered for treatment of abnormal uterine bleeding; evidence is insufficient to support its use for uterine leiomyoma symptoms other than bleeding.
Combined oral contraceptives may regulate and reduce menstrual bleeding, treat dysmenorrhea, reduce premenstrual dysphoric disorder symptoms, and ameliorate acne.
ACOG evidence level A.
Hormonal contraception should be considered for menorrhagia in individuals who may desire future pregnancies.
ACOG evidence level B.
NICE Management of Heavy Menstrual Bleeding
NICE recommendations for assessment and management of heavy menstrual bleeding include the following treatment pathways.
For no identified pathology, fibroids less than 3 cm, or suspected or diagnosed adenomyosis
Offer levonorgestrel-releasing intrauterine system (LNG-IUS) as first treatment.
If treatment is unsuccessful, the patient declines pharmacological treatment, or symptoms are severe, refer to a specialist to discuss additional options.
For fibroids greater than 3 cm
LNG-IUS may be considered as a pharmacological option.
Uterine artery embolization may be considered when fibroids are 3 cm or more in diameter.
Uterine Artery Embolization: Indications and Fertility Counseling
SIR states that UAE is indicated for uterine leiomyomata causing significant symptoms. Fertility counseling and individualized treatment selection are required when future pregnancy is relevant.
ONE or more significant symptoms
Heavy or prolonged menstrual bleeding.
Severe menstrual cramping.
Pelvic pressure, discomfort, excessive bloating, or fullness, particularly perimenstrual, or bothersome abdominal wall distortion caused by an enlarged uterus.
Pelvic pain related to identified leiomyomas, including dyspareunia.
Urinary urgency, frequency, nocturia, or retention related to an enlarged leiomyomatous uterus.
Focused Ultrasound Safeguards
NICE recommends ultrasound-guided high-intensity transcutaneous focused ultrasound for symptomatic uterine fibroids only with special arrangements for clinical governance, consent, and audit or research.
ALL of the following
Inform the clinical governance leads in the applicable health service trust.
Explain the procedure's recognized complications, including skin burns, limited-quality efficacy evidence, and uncertainties about safety and effectiveness.
Provide clear written information to support shared decision-making, including relevant NICE public information.
Audit and review clinical outcomes for all treated patients using relevant audit criteria or an audit tool.
During consent, explain that symptoms may not be completely relieved, may return, and may require further procedures.
Uterine Artery Embolization for Symptomatic Leiomyomata
SIR quality improvement guidance indicates UAE for uterine leiomyomata causing significant symptoms.
ONE or more significant leiomyoma-related symptoms
Heavy or prolonged menstrual bleeding.
Severe menstrual cramping.
Pelvic pressure, discomfort, excessive bloating, or fullness, particularly perimenstrual, or bothersome abdominal wall distortion caused by an enlarged uterus.
Pelvic pain related to identified leiomyomas, including dyspareunia.
Urinary urgency, frequency, nocturia, or retention related to an enlarged leiomyomatous uterus.
FDA approval alone is not a basis for coverage. This FDA section is for informational purposes only.