CurrentColorado Rocky Mountain Health PlansPolicy 2026T0442VV

Abnormal Uterine Bleeding and Uterine Fibroids

Clinical coverage policy for diagnosis and treatment options for abnormal uterine bleeding (AUB) and symptomatic uterine fibroids applicable to UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAbnormal Uterine Bleeding and Uterine Fibroids

Policy CodePolicy 2026T0442VV

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document prior authorization and required medical records when requesting uterine‑sparing procedures, including indication, device/system, uterine size, and reproductive plans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary interventions

4LNG-IUD products named

1–29%HIFU reintervention range

35.3%surgical reintervention rate

1policy scope: plan types

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for AUB and Uterine Fibroids

Endometrial Ablation (medical necessity)

Covered when ALL of the following are met

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

See InterQual for specific clinical entry criteria.

LNG-IUD (medical necessity and plan-specific rules)

Covered when ALL of the following are met

Levonorgestrel-releasing IUD (LNG-IUD): LNG-IUDs (e.g., Mirena, Skyla, Liletta, Kyleena) are proven and medically necessary for treating menorrhagia; coverage may be subject to preventive care benefits or plan-specific contraceptive exclusions — when contraception is excluded by the member's plan, LNG-IUD is covered for non-contraceptive indications including treatment of abnormal uterine bleeding.

Refer to FDA device approvals and the Preventive Care Services policy for product-specific preventive coverage.

Uterine Artery Embolization (medical necessity)

Covered when ALL of the following are met

Uterine artery embolization (UAE/UFE): UAE is proven and medically necessary for treating symptomatic uterine fibroids, postpartum or posthysterectomy bleeding, or uterine arteriovenous malformation; refer to InterQual CP: Procedures, Uterine Artery Embolization for clinical entry criteria.

Pre-procedure endometrial biopsy is recommended to rule out malignancy or hyperplasia; consider as an alternative to hysterectomy where appropriate.

Unproven or Not Medically Necessary Interventions

Not covered / Unproven

Unproven interventions: Magnetic resonance-guided focused ultrasound ablation (MRgFUS) is unproven and not medically necessary for treating uterine fibroids due to insufficient evidence of efficacy; UAE is unproven and not medically necessary when the stated goal is preservation of childbearing potential because evidence is insufficient to support fertility preservation.

Although MRgFUS CPT codes are listed, the modality is considered unproven for routine treatment of fibroids.

LNG-IUS (medical therapy) coverage rationale

Covered when supported by evidence and clinical indication

LNG-IUS for heavy menstrual bleeding (HMB): Levonorgestrel-releasing intrauterine system (LNG-IUS) is supported as a first-line nonsurgical therapy to reduce menstrual blood loss and improve quality of life in non-surgical candidates or those preferring uterine preservation, showing superior short- and medium-term outcomes versus oral medical treatments.

Based on multiple systematic reviews and RCTs (Cochrane and others) demonstrating greater reduction in blood loss, improved QOL, and higher satisfaction compared with oral therapies.

LNG-IUS long-term outcomes

Considerations after LNG-IUS

Reintervention risk after LNG-IUS: Long-term follow-up of randomized data shows similar overall reintervention risk compared with endometrial ablation strategies but a higher rate of surgical reintervention (driven by later endometrial ablation) in those treated initially with a 52‑mg LNG-IUS; most reinterventions occur within the first 24 months.

Counsel patients on the potential for later surgical procedures, including endometrial ablation or hysterectomy, despite effective bleeding reduction in many patients.

Uterine-sparing procedures coverage rationale

Uterine-sparing procedures (UAE, HIFU, MRgFUS, TFA) — coverage considerations

Efficacy and tradeoffs: Uterine-sparing procedures reduce fibroid size and improve bleeding and quality of life but have variable reintervention rates and mixed evidence for fertility preservation; selection should be individualized based on patient goals and evidence of comparative outcomes.

Meta-analyses report higher reintervention and hysterectomy rates for UAE versus myomectomy at longer follow-up but lower early complications; document counseling and individualized decision-making.

Fertility considerations: Evidence on post-procedure pregnancy rates and adverse pregnancy outcomes after UAE and other minimally invasive procedures is mixed and of low quality; some analyses report decreased postoperative pregnancy rates and increased risks such as postpartum hemorrhage or placenta previa after UAE.

When fertility preservation is a primary goal, prior authorization and detailed counseling are recommended due to uncertain outcomes and variable data quality.

Appropriate use and patient selection

Covered when ALL of the following are met

patient_selection: Patient has symptomatic uterine fibroids (e.g., heavy menstrual bleeding, bulk symptoms, pelvic pain) and desires uterine preservation or is otherwise an appropriate candidate for a uterine-sparing therapy.

ACR and ACOG list indications and recommend consideration of symptoms and reproductive goals; AAGL advises against ablative therapies for submucous myomas in patients desiring future fertility (Level C).

prior_treatment_trial: Medical management should generally be trialed prior to pursuing more invasive uterine-preserving procedures unless the clinical scenario requires immediate intervention.

ACR recommends trial of medical therapy for most reproductive-age patients; ACOG recommends surgical management for unstable or medical therapy–refractory acute AUB.

ref_extra_note":"Top-level nodes reflect ACR/ACOG/NICE recommendations."}],

Coverage considerations and device-specific indications

Coverage considerations derived from device approvals and FDA guidance:

LNG-IUD indication: LNG-IUDs (Mirena, Skyla, Liletta, Kyleena) are FDA‑approved for intrauterine contraception; Mirena additionally has FDA approval for treatment of heavy menstrual bleeding.

Document the brand and indication when requesting coverage.

MRgFUS indication: The ExAblate MRgFUS system received PMA approval for ablation of uterine fibroid tissue in pre- or perimenopausal women with symptomatic fibroids desiring uterine preservation; historical labeling limited uterine size to less than 24 weeks, and some later labeling removed completed childbearing restrictions—confirm current device labeling for patient selection.uterine size <24 weeks (historical)

Confirm device labeling and document uterine size and reproductive plans.

UAE considerations: UAE is a procedure (not device-regulated) though embolic agents used are FDA-regulated; selection of embolic agents and procedural planning should reflect available approvals and clinical evidence.

Some benefit plans exclude coverage for contraceptive services. In those plan documents, intrauterine devices (IUDs), including levonorgestrel‑releasing IUDs (LNG‑IUDs), are excluded when used for contraceptive purposes. When contraception is excluded, coverage for an LNG‑IUD may still be permitted if the device is used for a non‑contraceptive indication

When fertility preservation is the stated treatment goal, current evidence is limited and heterogeneous; studies on uterine‑sparing procedures report small sample sizes, low quality, and inconsistent long‑term follow‑up. As a result, procedures should not be presumed to reliably preserve childbearing potential and may be subject to case‑by‑case review or denial if fertility preservation cannot be supported by high‑quality evidence and documented counseling.

Specifically, uterine artery embolization (UAE) has insufficient evidence to conclude it preserves childbearing potential, and additional robust randomized data are needed to establish safety and long‑term pregnancy outcomes.

Ablative therapies — including uterine artery embolization, radiofrequency ablation, cryoablation, and magnetic resonance‑guided focused ultrasound (MRgFUS) — are not considered appropriate for women with submucous myomas who currently have infertility or who wish to conceive in the future. This recommendation is based on AAGL guidance (Level C consensus) citing insufficient evidence to support fertility preservation with these techniques; counsel patients accordingly and consider alternative fertility‑preserving options.

Laparoscopic power morcellators carry an FDA safety communication and are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy. The FDA also advises against morcellation for removal of uterine tissue containing suspected fibroids in peri‑ or postmenopausal women and in patients who are candidates for en bloc removal. Providers should follow FDA labeling, discuss the risks with patients, and avoid power morcellation in these identified situations.

Magnetic resonance‑guided focused ultrasound (MRgFUS) and uterine artery embolization (UAE) are addressed separately in this policy: MRgFUS is considered unproven and not medically necessary for treatment of uterine fibroids because of limited and low‑quality evidence and lack of standardized protocols. UAE is recognized as a medically necessary option for symptomatic fibroids in general, but evidence is insufficient to support its use specifically for fertility preservation.

Given variable study quality, inconsistent long‑term outcomes, and heterogeneous devices and techniques across the literature, MRgFUS should generally be regarded as investigational or limited to research settings outside clearly defined indications.

MRgFUS is considered investigational or should be limited when used outside controlled research because of a paucity of standardized treatment protocols, short follow‑up in most studies, and generally low‑quality evidence for long‑term symptom relief and durability. These limitations affect the reliability of outcome estimates and the ability to generalize findings across patient populations and devices.

Comparative data for MRgFUS versus other uterine‑preserving options are limited and inconsistent. Systematic reviews and clinical assessments report lower quality evidence, with some comparisons showing less symptom improvement and higher reintervention after MRgFUS versus alternatives such as UAE. Because of low‑quality and heterogeneous evidence, the net clinical benefit of MRgFUS relative to established treatments remains uncertain and patient selection should be cautious.

The FDA safety communication identifies specific situations in which power morcellation is associated with unacceptably high risk of spreading occult malignancy and is contraindicated. Use of power morcellation in patients with suspected uterine malignancy, in peri‑ or postmenopausal patients, or when en bloc removal is feasible is discouraged and may be considered not medically necessary. Document counseling and follow FDA recommendations when planning specimen extraction.

Procedure, Supply, and Device Coding

Applicable procedure CPT/HCPCS codesmixed

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).

Applicable J/S codes for LNG-IUD and implantmixed

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.

Referenced devices/communications (no billing codes provided)mixed

N/A	Document lists device approvals (e.g., Mirena, Skyla, Liletta, Kyleena; ExAblate PMA P040003) and FDA communications (power morcellation warning) but does not enumerate CPT/ICD billing codes in this section.

inv-22: NPVR success threshold

NPVR success threshold> 80%

NPVR roleNonperfused volume ratio correlated with clinical success after focused ultrasound ablation

MR-HIFU vs US-HIFU NPVRReported NPVR for MR-HIFU 58.92% vs US-HIFU 81.07%

inv-23: Fibroid volume inclusion/consideration

Volume inclusion in MR-HIFU studiesFibroids with volume < 300 cm3 were included in MR-HIFU studies

NICE size threshold for UAE considerationNICE lists fibroids ≥ 3 cm in diameter as eligible for UAE consideration

Provider Requirements, Prior Authorization, and Documentation

Documentation Required
Code listing and benefit determination
The following procedure, device, and supply codes are provided for reference only. Inclusion does not guarantee coverage; benefit determination is made by the member-specific benefit plan and applicable law. Medical records documentation may be requested to confirm that clinical criteria and prior conservative treatments have been met.
Applicable procedure and supply codes (examples): 0071T, 0072T, 37243, 58563
Applicable device and drug codes (examples): J7296, J7297, J7298, J7301, J7306, S4981

Prior Authorization
Prior authorization recommended for uterine‑sparing procedures
Prior authorization is recommended for uterine‑sparing procedures (for example MRgFUS, UAE, myomectomy) to allow review of indication, prior treatments, and patient counseling about risks, reintervention rates, and fertility considerations. Submit relevant medical records, imaging, and documentation of prior conservative management.

Definitions and Background

Abnormal uterine bleeding (AUB) encompasses any change in menstrual period frequency or duration, a change in the amount of flow, or bleeding between cycles. In postmenopausal individuals, AUB includes vaginal bleeding occurring 12 months or more after cessation of menses. This terminology covers clinical patterns such as menorrhagia and metrorrhagia and frames indications for medical and procedural therapies described in this policy.

inv-42: Abnormal uterine bleeding (AUB) — definition and scope

DefinitionAbnormal uterine bleeding (AUB) is any change in menstrual period frequency or duration, a change in amount of flow, or any bleeding between cycles; in postmenopausal women includes vaginal bleeding ≥12 months after cessation of menstruation

Included termsIncludes oligomenorrhea, polymenorrhea, menorrhagia, menometrorrhagia, and metrorrhagia

Clinical focusPolicy focuses on treatment options when bleeding pattern is abnormal; conservative management includes watchful waiting and pharmacologic therapy

inv-43: Uterine fibroids (leiomyomata) — definition and common symptoms

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAbnormal Uterine Bleeding and Uterine Fibroids

Policy CodePolicy 2026T0442VV

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document prior authorization and required medical records when requesting uterine‑sparing procedures, including indication, device/system, uterine size, and reproductive plans.

SourceLink

On This Page

Document use of approved embolic agents when applicable.

Morcellation contraindications: Laparoscopic power morcellators carry FDA warnings and contraindications: they are contraindicated when tissue is known or suspected to contain malignancy and in peri- or post‑menopausal women or when en bloc removal is feasible; use is discouraged for many women undergoing myomectomy or hysterectomy due to risk of spreading occult cancer.

Follow FDA guidance and document counseling if morcellation is considered.

Evidence limitations noteStudies note poor documentation of fibroid number/location and limited long-term outcomes when considering volume-based inclusion

inv-24: Uterine size limit

Uterine size limit (device indication)Historically indicated for uterine size less than 24 weeks (ExAblate PMA labeling)

Labeling change note2015 labeling update removed completed childbearing restriction but retained uterine size consideration in original approval text

Confirm device labelingPolicy recommends confirming current device labeling and patient suitability prior to procedure

Document prior medical management (e.g., NSAIDs, tranexamic acid, hormonal therapy) and response

For MRgFUS, include device/system (e.g., ExAblate PMA P040003) and treatment details

Note
Specialized‑center and informed‑consent requirements
Some uterus‑preserving procedures have variable outcomes and eligibility constraints. Patient selection should be performed by a multidisciplinary team and, where applicable, procedures should be performed in specialized centers by clinicians with specific training. During informed consent, discuss uncertain efficacy, possible need for further procedures, potential skin burns (MRgFUS), and uncertain effects on future fertility.
Multidisciplinary selection (gynecology + imaging specialist) recommended
Perform procedure in specialized center with trained clinicians
Consent must address uncertain fertility effects and possibility of additional interventions

Documentation Required
Documentation requirement
Medical records and supporting documentation are required to assess coverage and may include history of symptoms, imaging (ultrasound/MRI) describing size/number/location of fibroids, documentation of prior medical therapies and duration, and fertility desires. Absence of required documentation may lead to denial of the request.
Required: clinic notes describing indication and prior treatments
Required: imaging reports (ultrasound and/or MRI) with fibroid measurements and location
Required: documentation of device used and indication (e.g., specific LNG‑IUD brand vs contraceptive use)

Denial Risk
UAE fertility evidence limitations
Evidence regarding fertility outcomes after uterine artery embolization (UAE) is limited and inconsistent. Counsel patients that UAE may be associated with higher reintervention and hysterectomy rates than myomectomy and that long‑term pregnancy outcomes are not well established.
Inform patients that studies are often small, observational, and lack long‑term follow up
Document counseling about potential impact on fertility and alternative options (e.g., myomectomy)

Denial Risk
Patient eligibility and exclusion criteria
Numerous patient eligibility issues and exclusion criteria apply for some uterine‑sparing techniques (notably MRgFUS). Clinicians must screen for contraindications, consider procedure duration and anesthesia needs, and document why the patient is an appropriate candidate.
MRgFUS: many exclusions (e.g., fibroid characteristics, body habitus, proximity to sensitive structures) — document eligibility assessment
Consider anesthesia and prolonged procedure time in planning and documentation

Documentation Required
Documentation of indication and prior treatment
Document the specific clinical indication (e.g., heavy menstrual bleeding vs contraception), prior treatments tried and duration, and rationale for escalation to device/procedure-based therapy. This should include prior trial of medical management when appropriate.
Record prior medications and durations (eg, tranexamic acid, oral contraceptives, progestogens, LNG‑IUS trial)
If prior conservative therapy declined or contraindicated, document reason

Documentation Required
Device and indication documentation
When a device or system is used, document the exact device and indication (for example: Mirena, Liletta, Kyleena, Skyla for LNG‑IUD; ExAblate 2000/2100 for MRgFUS). Distinguish use for contraception versus therapeutic treatment of heavy menstrual bleeding in the documentation.
Include device model/manufacturer and FDA indication where applicable
Differentiate contraceptive versus non‑contraceptive (therapeutic) indication for LNG‑IUD

Step Therapy
Conservative treatment before surgery
Conservative (non‑surgical) treatment should generally be attempted before surgery for reproductive‑age women unless contraindicated or if symptoms/severity require more urgent intervention. LNG‑IUD is an effective first‑line nonsurgical option for heavy menstrual bleeding and should be considered and documented as part of conservative care.
Document trial of medical management (NSAIDs, antifibrinolytics, hormonal therapy) and/or LNG‑IUD and treatment response
If LNG‑IUD used, specify brand and whether used for contraception or for treatment of abnormal uterine bleeding

Prior Authorization
Trial of medical management recommended
For reproductive‑aged patients, medical management (including LNG‑IUS) should generally be trialed before more invasive uterine‑preserving therapies. If proceeding without a trial, document clinical justification (e.g., severity, patient preference, contraindication to medical therapy).
Record duration and response to medical therapy prior to authorization of invasive procedures
If immediate procedure selected, document reasons and counseling provided

Step Therapy
LNG‑IUD as therapeutic step
Consider levonorgestrel‑releasing IUDs (Mirena, Liletta, Kyleena, Skyla) as therapeutic options for heavy menstrual bleeding; when used for non‑contraceptive indications, document indication to ensure coverage where contraceptive benefits may be excluded by plan.
If plan excludes contraception, claim/authorization must document non‑contraceptive indication (e.g., HMB) for LNG‑IUD coverage
Include J‑code (J7296–J7301) or S4981 insertion code when billing

DefinitionUterine fibroids (leiomyomata) are benign tumors of the uterus

Common symptomsMay cause excessive uterine bleeding, uterine enlargement/mass, pelvic pain/pressure, urinary frequency, and abdominal distension

Typical age groupMost commonly found in women aged 30–40 years but can occur at any age

inv-44: LNG-IUS (52 mg) — description as levonorgestrel-releasing intrauterine system

Product descriptionLevonorgestrel-releasing intrauterine system (LNG-IUS) releasing ~20 µg/day initially from a 52 mg reservoir

Therapeutic useUsed as long-term medical therapy for heavy menstrual bleeding with superior short- and medium-term outcomes versus many oral medical treatments

Examples/approvalsFDA-approved products include Mirena, Liletta (52 mg), with Skyla and Kyleena as alternative LNG systems

inv-45: UAE — definition of uterine artery embolization

DefinitionUterine artery embolization (UAE) is an image-guided procedure that occludes uterine arteries supplying fibroids to reduce fibroid size and symptoms

Regulatory noteUAE procedure is not device‑regulated, but embolic agents used are subject to FDA oversight

Clinical considerationsAssociated with reductions in fibroid size and symptoms but has mixed evidence regarding fertility outcomes and higher reintervention rates versus myomectomy in some analyses

inv-46: HIFU / MRgFUS — definition of high-intensity focused ultrasound and MR-guided focused ultrasound

DefinitionHigh‑intensity focused ultrasound (HIFU) and magnetic resonance‑guided focused ultrasound (MRgFUS) are noninvasive uterine‑sparing ablation techniques using focused ultrasound energy to thermally ablate fibroid tissue

Outcome variabilityEvidence shows variable reintervention rates and limited long‑term data; treatment protocols are not standardized across studies

Device examples and AEsDevices include ExAblate and Sonalleve; common AEs reported include pain and skin burns, with device‑specific AE rates reported in systematic reviews

inv-47: NPVR — nonperfused volume ratio and success threshold

DefinitionNonperfused volume ratio (NPVR) is the proportion of treated fibroid volume that is nonperfused after focused ultrasound ablation and is correlated with clinical success

Success threshold> 80% NPVR is considered successful

Clinical relevanceHigher NPVR is associated with lower reintervention rates after HIFU/MRgFUS

inv-48: LNG-IUD / LNG-IUS — product indications for contraception and heavy menstrual bleeding

IndicationsLNG‑IUD/LNG‑IUS devices are FDA‑approved for intrauterine contraception; some products (e.g., Mirena) also have an FDA indication for treatment of heavy menstrual bleeding

Therapeutic roleRecommended as first‑line nonsurgical therapy to reduce menstrual blood loss in non‑surgical candidates and to improve quality of life

Plan‑coverage caveatCoverage may be subject to preventive care benefits or plan‑specific contraceptive exclusions; when contraception is excluded, LNG‑IUD may be covered for non‑contraceptive indications like AUB

inv-49: MRgFUS — ExAblate system indication and PMA context

ExAblate PMA indicationExAblate 2000/2100 System (Insightec) received PMA P040003 for ablation of uterine fibroid tissue in pre‑ or perimenopausal women desiring uterine preservation

Historical uterine size limitOriginal PMA indicated uterine size less than 24 weeks; 2015 update removed completed‑childbearing restriction

Device labeling confirmationPolicy advises documenting device/system (e.g., ExAblate PMA P040003) when requesting authorization

inv-50: UAE — image-guided embolization and embolic agent regulation note

Procedure descriptionUAE is an image‑guided embolization procedure that occludes uterine arteries feeding fibroids to induce ischemia and shrinkage

Embolic agent regulationEmbolic agents used in UAE are subject to FDA oversight and some agents have specific FDA approvals for UAE

Fertility evidence cautionInsufficient high‑quality evidence exists to conclude UAE preserves childbearing potential; fertility outcomes are mixed and may require case‑by‑case review