CurrentColorado Rocky Mountain Health PlansPolicy MMP098.10

Uterine Services and Procedures

Medicare Advantage policy describing coverage guidance and coding for uterine procedures (uterine artery embolization for fibroids, MRI-guided focused ultrasound ablation, and hysterectomy) as applied by UnitedHealthcare Medicare Advantage plans and intended for providers submitting claims or prior authorization requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUterine Services and Procedures

Policy CodePolicy MMP098.10

Change TypeRevised clinical language and referral guidanceadministrative archival

Effective DateOct 1, 2025

Next Review Date

Key ActionObtain prior authorization per UnitedHealthcare Medicare Advantage internal criteria and submit complete supporting documentation when requesting UAE or other uterine procedures.

SourceLink

POLICY UPDATE CHANGES

Replaced language indicating 'Medicare does not have a National Coverage Determination (NCD) for hysterectomy' with 'Medicare does not have an NCD for hysterectomy for benign conditions'.

Replaced instruction to refer to the UnitedHealthcare Commercial Medical Policy titled Hysterectomy with a more specific referral to that policy 'for all other indications not listed in the NCD for Sterilization (NCD 230.3)'.

Added References section to Supporting Information.

Archived previous policy version MMP098.09.

3Primary procedure types discussed

~40+CPT procedure codes listed

Medicare AdvantageApplicability (plan type)

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Coverage Criteria and Policy Stance

UAE Coverage Rationale

UAE for treatment of uterine fibroids is reviewed using UnitedHealthcare commercial policy criteria supplemented by general Medicare guidance where no specific NCD/LCD exists.

UAE coverage rationale: Use UnitedHealthcare Commercial Medical Policy criteria to determine reasonable and necessary use of UAE for uterine fibroids or severe dysfunctional uterine bleeding; these criteria supplement general Medicare guidance when no specific NCD/LCD exists.

Internal criteria applied when Medicare NCD/LCD absent

MRI-Guided Focused Ultrasound Coverage

MRI-guided focused ultrasound ablation has no Medicare NCD; coverage follows UnitedHealthcare Commercial Medical Policy criteria.

MRI-guided focused ultrasound guidance: Refer to the UnitedHealthcare Commercial Medical Policy titled Abnormal Uterine Bleeding and Uterine Fibroids for coverage criteria for MRI-guided focused ultrasound ablation; Medicare does not have an NCD and LCDs/LCAs do not exist.

Hysterectomy Coverage Stance

Hysterectomy for benign conditions: Medicare does not have an NCD; for sterilization refer to NCD 230.3.

Hysterectomy guidance: Elective hysterectomy or tubal ligation when the primary indication is sterilization is nationally non-covered per NCD 230.3; for all other indications refer to the UnitedHealthcare Commercial Medical Policy titled Hysterectomy for coverage guidance.

Elective hysterectomy or tubal ligation when the primary indication is sterilization is nationally non‑covered. Refer to NCD 230.3 (Sterilization) for coverage guidance on sterilization procedures; for other indications see the referenced UnitedHealthcare Commercial Medical Policy for Hysterectomy as applicable.

This policy supplements Medicare guidance with UnitedHealthcare Commercial Medical Policy criteria to guide determinations for procedures such as UAE. These internal criteria are intended to promote consistency so that procedures are not incorrectly denied when medically appropriate nor incorrectly approved when not reasonable and necessary. Caution: misapplication of these internal criteria can lead to inappropriate denials (for example, withholding a needed UAE that could prevent ongoing anemia, pain, or compressive symptoms) or inappropriate approvals that expose members to unnecessary procedural risks. Explicit not‑medically‑necessary conditions beyond sterilization are governed by the referenced commercial policies and the member’s benefit documents.

Procedure and CPT/HCPCS Coding

UAE for Uterine FibroidsCPTCovered

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.

MRI-Guided Focused Ultrasound AblationCPTCovered

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.

Hysterectomy CPT CodesCPTCovered

58150	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s).
58152	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch).
58180	Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s).
58260	Vaginal hysterectomy, for uterus 250 g or less.
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s).
58263	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele.
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control.
58270	Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele.
58290	Vaginal hysterectomy, for uterus greater than 250 g.
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).

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inv-09: Leiomyomata volume — mapping of 0071T and 0072T to volume thresholds

CPT 0071TFocused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue.

CPT 0072TFocused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue.

Volume mapping summary0071T is used when total leiomyomata volume is <200 cc; 0072T is used when total leiomyomata volume is >=200 cc.

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Expectations

Prior authorization and coverage determinations for Uterine Artery Embolization (UAE) are governed by UnitedHealthcare Medicare Advantage internal criteria and member-specific factors. Providers should verify prior authorization requirements before scheduling services and follow any delegate requirements when applicable.

Prior authorization may be required and is determined using UnitedHealthcare Medicare Advantage medical necessity criteria and the member’s benefit plan.
If a delegate manages prior authorization for the member’s plan, follow the delegate’s authorization process and requirements.

Documentation Required

Documentation and Claims Accuracy

Providers must retain clinical records and documentation that support medical necessity for UAE. Documentation should be complete, contemporaneous, and available upon request to support coverage decisions and appeals.

Background and Clinical Context

Uterine artery embolization (UAE) and MRI‑guided focused ultrasound ablation are minimally invasive alternatives to hysterectomy for symptomatic uterine fibroids. UAE can reduce bleeding and bulk symptoms but carries risks including post‑embolization syndrome (pelvic pain, cramping, vaginal discharge, nausea, vomiting, fatigue, and discomfort), infection, infarction of uterine tissue, and vascular complications. MRI‑guided focused ultrasound ablation is an option for selected patients and is subject to volume‑based coding thresholds described elsewhere in this policy.

Definitions and Key Terms

inv-15: post-embolization syndrome definition — list symptoms and brief description

Core symptomsPelvic pain and cramping following uterine artery embolization.

Associated symptomsVaginal discharge, nausea, vomiting, fatigue, and general discomfort after the procedure.

Clinical significancePost-embolization syndrome is a constellation of these symptoms that can occur after UAE and may require symptomatic management.