RetiredUnitedHealthcarePolicy CS002LA.AB

Abnormal Uterine Bleeding Uterine Fibroids La Cs

UnitedHealthcare Louisiana medical policy (Part 1 of 2) addressing coverage positions and clinical evidence summaries for endometrial ablation, levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), and magnetic resonance-guided focused ultrasound (MRgFUS) for abnormal uterine bleeding and uterine fibroids. Includes applicable CPT/HCPCS codes and documentation expectations; references InterQual for specific medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyAbnormal Uterine Bleeding Uterine Fibroids La Cs

Policy CodePolicy CS002LA.AB

Change TypeRetired (state plan)

Effective DateJan 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation (history, physical exam, diagnostic test results) that fully supports medical necessity and make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Policy retired April 1, 2026; effective coverage period noted January 1, 2026 - March 31, 2026.

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

Added Medical Records Documentation Used for Reviews language on 01/01/2026.

Updated Clinical Evidence and References sections to reflect current information; archived prior policy version CS002LA.AA.

4Interventions addressed

9CPT/HCPCS codes listed

Retired state plan noted

>80%NPVR success threshold

Coverage Summary

Policy retired April 1, 2026; effective Jan 1, 2026 - Mar 31, 2026. This UnitedHealthcare Louisiana medical policy (CS002LA.AB, Part 1 of 2) addresses coverage positions, applicable CPT/HCPCS codes, documentation expectations, and clinical evidence summaries for interventions used to manage abnormal uterine bleeding (AUB) and uterine fibroids in Louisiana members. Interventions addressed include endometrial ablation, levonorgestrel-releasing intrauterine devices (LNG-IUDs), uterine artery embolization (UAE), and magnetic resonance-guided focused ultrasound (MRgFUS/HIFU). The document references InterQual for specific medical necessity criteria and lists CPT/HCPCS codes and device information relevant to these procedures.

Key thresholds & quick facts

NPVR success threshold> 80% considered successful

Reported NPVR examplesMR-HIFU 58.92% vs US-HIFU 81.07%

ExAblate (PMA) uterine size limitIndicated for uterine size < 24 weeks

NICE LNG-IUS fibroid size noteLNG-IUS recommended first-line for fibroids < 3 cm

Policy retirement notePolicy retired April 1, 2026 (Louisiana plan disenrolled)

Medical‑Necessity Criteria

Endometrial Ablation - Coverage Position

Covered when InterQual CP: Procedures, Hysteroscopy, Operative medical necessity criteria are met:

Primary coverage statement: Endometrial ablation is proven and medically necessary for treating abnormal uterine bleeding in premenopausal individuals.
Member meets medical necessity clinical coverage criteria as defined by InterQual CP: Procedures, Hysteroscopy, Operative (external criteria referenced).

InterQual reference note: Medical necessity determinations for endometrial ablation require review against InterQual CP: Procedures, Hysteroscopy, Operative criteria.

InterQual referenced for detailed criteria.

Levonorgestrel‑Releasing Intrauterine Device (LNG‑IUD) - Coverage Position

Covered when FDA indications or referenced evidence support use:

Coding

Focused ultrasound ablation (FUS) CPT codesCPTExperimental

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.

Uterine artery embolization codeCPTCovered

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.

Endometrial ablation codeCPTCovered

58563

Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation).

Levonorgestrel-Releasing Intrauterine Device (Drug) HCPCS codesHCPCS|NDCCovered

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.

Devices and drugs referenced (informational only)mixed

ExAblate 2000/2100	Insightec MRgFUS system; PMA P040003; indicated for ablation of uterine fibroid tissue in pre-/perimenopausal women with symptomatic fibroids and uterine size <24 weeks; 2015 labeling removed completed childbearing restriction.
Mirena	Levonorgestrel-releasing intrauterine system; FDA approval Dec 8, 2000; HMB indication added Oct 1, 2009.
Skyla	LNG-IUD; FDA approval Jan 9, 2013 (contraceptive).
Liletta	LNG-IUD; FDA approval Feb 26, 2015 (contraceptive).
Kyleena	LNG-IUD; FDA approval Sep 16, 2016 (contraceptive).
Laparoscopic power morcellator	Class II medical device; FDA Safety Communication (Nov 24, 2014) includes black box warning and contraindications.

Provider Actions & Operational Guidance

Documentation Required

Medical record documentation for medical necessity

The patient's medical record must contain documentation that fully supports the medical necessity for the requested service(s). Records should be legible, maintained in the patient's medical record, and made available upon request to verify that clinical criteria are met. Documentation must support the indications and elements noted below and may be required during prior authorization or post-payment review.

Relevant medical history (e.g., duration and pattern of bleeding, prior therapies and response)
Physical examination findings pertinent to AUB or fibroids
Results of diagnostic tests and procedures (e.g., pelvic ultrasound, MRI, endometrial biopsy, laboratory studies, hemoglobin/hematocrit)
Documentation of conservative management trials and response (medications, devices such as LNG-IUD, duration of therapy)
InterQual or other evidence-based criteria outputs when utilized (e.g., CP: Hysteroscopy, Operative; CP: Uterine Artery Embolization)
Procedure-specific rationale and risk/benefit discussion in the record (e.g., reason for endometrial ablation vs other treatments, indication for UAE)
Operative and pathology reports when applicable

Background and Definitions

Abnormal uterine bleeding (AUB) is defined in reproductive-age women as any change in menstrual frequency, duration, amount of flow, or bleeding between cycles; postmenopausal bleeding is defined as bleeding ≥12 months after cessation of menstruation. AUB includes patterns such as oligomenorrhea, polymenorrhea, menorrhagia (heavy flow or >7 days), menometrorrhagia, and metrorrhagia. Conservative management options for AUB include watchful waiting and pharmacologic therapy (for example hormonal therapy, which may temporarily reduce fibroid size but the effect may reverse after discontinuation), dilation and curettage, and hysterectomy when symptoms are refractory to conservative care.

Uterine fibroids (leiomyomata) are benign, well-vascularized uterine tumors commonly seen in women aged ~30–40 years and may cause heavy bleeding, uterine enlargement, bulk-related symptoms (pelvic pressure, urinary frequency), and pain. Treatment options span conservative medical therapies (including LNG-IUDs for heavy menstrual bleeding), minimally invasive uterine-sparing procedures (for example uterine artery embolization (UAE), image-guided thermal ablation techniques, and MRgFUS/HIFU), and surgical options up to hysterectomy. UAE works by injecting particles to occlude the fibroid blood supply causing shrinkage; MRgFUS/HIFU uses focused ultrasound energy with MR guidance to thermally ablate fibroid tissue; LNG-IUDs deliver levonorgestrel locally to induce endometrial atrophy and reduce bleeding. Uterine-sparing procedures are used to control symptoms while preserving the uterus and potentially shortening recovery compared with hysterectomy.

Key definitions

Evidence sources

Clinical Evidence Highlights

Numeric evidence metrics

RFA pooled fibroid volume reduction (6 mo)70% (Taheri et al. 2019)

UAE pooled fibroid volume reduction (6 mo)54% (Taheri et al. 2019)

FUS pooled fibroid volume reduction (6 mo)32% (Taheri et al. 2019)

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

ExAblate regulatory statusExAblate 2000/2100 PMA P040003 (label updates; 2015 removed completed-childbearing restriction)

Guidance from professional bodies and regulatory authorities is reflected in the policy. ACOG acknowledges MRgFUS data are limited and that MRgFUS may provide leiomyoma and uterine volume reduction but shows less symptom improvement and higher reintervention compared with UAE in some comparative data; ACOG also recommends preoperative evaluation and counseling regarding uterine morcellation risks and advises shared decision-making about surgical approaches.

Revision History

2026-01-01added

Added 'Medical Records Documentation Used for Reviews' language clarifying that benefit coverage is determined by federal, state, or contractual requirements and outlining required medical record documentation to support medical necessity (history, physical exam, and diagnostic test/procedure results).

2026-01-01revised

Updated Clinical Evidence and References sections to reflect current information and archived prior policy version CS002LA.AA.

2026-04-01revisedLatest

Policy Summary

PayerUnitedHealthcare

PolicyAbnormal Uterine Bleeding Uterine Fibroids La Cs

Policy CodePolicy CS002LA.AB

Change TypeRetired (state plan)

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

LNG-IUD - Coverage Position: LNG-IUDs (e.g., Mirena, Skyla, Liletta, Kyleena) are proven and medically necessary for treating menorrhagia.

Policy references multiple systematic reviews and RCT follow-ups to support efficacy; device insertion code S4981 included.

Additional indications and clinical judgement: LNG-IUD may be used for management of adenomyosis and inherited bleeding disorders and HMB per cited evidence; consider device-specific evidence and clinician judgment.

Refer to FDA labeling and systematic reviews for indication specifics and evidence.

Uterine Artery Embolization (UAE) - Coverage Position

Covered when InterQual CP: Procedures, Uterine Artery Embolization medical necessity criteria are met:

UAE - Primary coverage statement: UAE is proven and medically necessary for treating symptomatic uterine fibroids, postpartum or post-hysterectomy bleeding, or uterine arteriovenous malformation (AVM).

Member must meet InterQual CP: Procedures, Uterine Artery Embolization criteria for medical necessity.

Fertility preservation exclusion: UAE is unproven and not medically necessary for the purpose of preserving childbearing potential for individuals with symptomatic uterine fibroids due to insufficient evidence of efficacy.

Insufficient evidence of efficacy for fertility preservation.

InterQual reference note: Medical necessity determinations for UAE require review against InterQual CP: Procedures, Uterine Artery Embolization criteria.

Refer to InterQual for detailed criteria.

Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) / HIFU - Coverage Position

Policy position based on evidence synthesis:

MRgFUS/HIFU - Coverage Position: MRgFUS is unproven and not medically necessary for treating uterine fibroids due to insufficient evidence of efficacy.

Evidence is limited by lack of long-term durability data and inconsistent protocols; additional robust RCTs needed.

Evidence limitations: Evidence is limited by small studies, heterogenous protocols, short follow-up, and risk of bias; comparative data show higher reintervention rates versus some alternatives.

Further high-quality RCTs and standardized protocols are needed.

Clinical evidence and appropriateness summary

Evidence-based conclusions and guideline summaries regarding procedures:

MRgFUS/MRgHIFU evidence summary: Evidence shows short-term reduction in leiomyoma and uterine size; limited long-term data and higher reintervention rates compared with UAE; procedure length and eligibility limitations reduce mainstream adoption; NPVR > 80% considered successful (example NPVRs: MR-HIFU 58.92%, US-HIFU 81.07%).>80% NPVR considered successful

Efficacy and safety considered limited/inconclusive by ECRI; NICE supports use only with clinical governance/audit or in research.

US-HIFU comparative metrics: US-HIFU reported higher NPVR (~81.07%) and shorter mean treatment time (mean 96.9 minutes) relative to MR-HIFU in cited meta-analysis.

Performance metrics cited from comparative analyses/meta-analyses.

RFA and microwave ablation summary: RFA and microwave ablation systematic reviews suggest substantial fibroid volume reduction (RFA pooled ~70% at 6 months) and acceptable safety in small studies; larger randomized prospective trials needed.

Ierardi et al. 2018 found microwave ablation safe in small series but called for larger studies.

UAE guideline and outcomes summary: UAE pooled data show symptom relief short- and medium-term; ACOG recommends UAE as an option for uterine preservation with counseling on limited reproductive outcome data; SIR indicates UAE is indicated for significant symptomatic leiomyomata with specific symptom list provided.

NICE and ACR appropriateness criteria support UAE in specific scenarios.

LNG-IUD evidence summary: Evidence supports LNG-IUD for heavy menstrual bleeding; ACOG and NICE recommend LNG-IUD as a treatment option and as first-line in certain scenarios (eg, fibroids <3 cm or no identified pathology); Mirena has FDA HMB indication.fibroids <3 cm per NICE for first-line LNG-IUS

Evidence from Cochrane and multiple RCTs/meta-analyses supports efficacy for HMB.

Morcellation cautions: FDA Safety Communication (2014) warns against power morcellation in most women due to risk of spreading unsuspected cancer; contraindicated when malignancy is known/suspected and in peri/postmenopausal women or when en bloc removal is possible.

Black box warning and contraindications must be included in device labeling per FDA.

Documentation and pre-review requirements

Medical records documentation used for reviews (policy language added 01/01/2026):

Federal/state/contractual coverage caveat: Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws; such requirements may mandate coverage for specific services and govern in the event of conflict.

Operational guidance for reviewers.

Documentation supports medical necessity: Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the services requested.

Documentation must fully support medical necessity for requested services.

Required documentation elements: Required documentation includes relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the patient's medical record, and made available upon request.

Added language clarifying documentation expectations (01/01/2026).

Informed consent documentation including counseling on risks and alternatives

Prior Authorization

InterQual referenced prior authorization/medical necessity checks

InterQual clinical pathways/CP criteria are referenced for medical necessity determinations for endometrial ablation and uterine artery embolization. A formal InterQual review (or documented equivalent clinical-criteria review) may be required as part of prior authorization or medical necessity adjudication.

Affected codes: 58563, 37243

Denial Risk

UAE for fertility preservation not covered

Uterine artery embolization (UAE) performed for the primary purpose of preserving future childbearing potential is considered unproven and may be denied as not medically necessary. Providers should document fertility counseling and alternatives when fertility preservation is a concern.

Affected code: 37243

Documentation Required

Informed consent and patient counseling for morcellation

Clinicians should evaluate the risk of an occult uterine malignancy preoperatively and counsel patients about the potential risk of dissemination with morcellation. Informed consent must reflect discussion of the potential for spreading an undetected cancer and alternatives to power morcellation. Refer to FDA communications (e.g., 2014 safety communication) for additional guidance.

Prior Authorization

Potential prior authorization and benefit determination

Coverage is subject to federal, state, and contractual requirements; prior authorization or medical-record review may be required to determine benefit coverage. Providers should verify member eligibility, benefit limitations, and prior authorization requirements with UnitedHealthcare before scheduling services.

NICE recommends use of ultrasound-guided HIFU/MRgFUS only with clinical governance, consent, audit, or research arrangements and advises informing patients about uncertainties in efficacy and potential need for further procedures; NICE also lists LNG-IUS as first-line for heavy menstrual bleeding when no pathology or for fibroids <3 cm and includes UAE as an option for fibroids ≥3 cm with appropriate imaging assessment. The FDA issued a safety communication (November 24, 2014) recommending prominent device labeling (black box warning) for power morcellators and contraindicating morcellation when uterine malignancy is known or suspected, in peri-/postmenopausal women, or when en bloc removal is possible.

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026. Document header states 'Retired April 1, 2026' and effective coverage period noted January 1, 2026 - March 31, 2026.