Abnormal Uterine Bleeding and Uterine Fibroids (for Kentucky Only)

Coverage Summary

Scope: This UnitedHealthcare Kentucky policy (Policy Number CS002KY.10; effective date November 1, 2025) addresses coverage and clinical guidance for abnormal uterine bleeding (AUB) and uterine fibroid treatments in Kentucky.

Coverage stance: Mixed — some interventions are described as proven/medically necessary while others are considered unproven/not medically necessary depending on indication and supporting evidence.

Interventions addressed: the policy covers endometrial ablation, levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), and magnetic resonance-guided focused ultrasound ablation (MRgFUS), with specific coverage positions for each.

Key notes: Endometrial ablation and LNG-IUD are described as proven and medically necessary for specified indications; UAE is proven and medically necessary for symptomatic fibroids and certain bleeding indications but not medically necessary when used solely to preserve childbearing potential; MRgFUS is described as unproven and not medically necessary for treating uterine fibroids. The policy references InterQual modules for specific clinical criteria/authorization requirements.

Quick facts & threshold highlights

NPVR success threshold> 80% (Nonperfused Volume Ratio > 80% considered successful)

Uterine size for ExAblate indicationUterine size less than 24 weeks' size (per FDA PMA labeling for ExAblate)

Fibroid size reference for LNG-IUS per NICELNG-IUS first-line for fibroids < 3 cm; for fibroids ≥ 3 cm LNG-IUS is a pharmacologic option

Primary treatment categories addressed4

Policy versionsCS002KY.09 archived prior version

Medical-Necessity Criteria (grouped by intervention)

Endometrial Ablation - Medically Necessary

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

Indication: Treatment is for abnormal uterine bleeding in premenopausal individuals.
Refer to InterQual CP: Procedures, Hysteroscopy, Operative for medical necessity clinical coverage criteria.

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD) - Medically Necessary

Covered for treatment of menorrhagia/ heavy menstrual bleeding and other specified indications when clinically appropriate.

LNG-IUD - Indications and evidence: Use of LNG-IUD (e.g., Mirena, Skyla, Liletta, Kyleena) for menorrhagia is proven and medically necessary.

FDA approvals and multiple systematic reviews support use for heavy menstrual bleeding.

Coding

Uterine Fibroids - Relevant CPT/HCPCS Codes (reference list)mixed

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 - Drug & Insertion Codesmixed

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.

No procedural or diagnosis codes listed in this partmixed

No codes listed

Provider Actions & Authorization Requirements

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested service. Required documentation includes relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures (for example: imaging, laboratory tests, endometrial biopsy, or hysteroscopy findings). Documentation must be legible, maintained in the patient's medical record, and made available upon request for review.

Prior Authorization

InterQual criteria-based prior authorization

Providers should follow the InterQual® criteria when requesting prior authorization for procedures covered under this policy (for example, endometrial ablation, uterine artery embolization). Authorization requests will be reviewed against the InterQual requirements.

Background and Evidence Summary

Background: The policy defines abnormal uterine bleeding (AUB) as any change in menstrual frequency or duration, amount of flow, or bleeding between cycles (postmenopausal bleeding defined as vaginal bleeding ≥12 months after cessation of menstruation), and lists AUB terms including menorrhagia and others.

Uterine fibroids (leiomyomata) are described as benign uterine tumors that can cause heavy bleeding, uterine enlargement, and bulk symptoms (pelvic pain, pressure, urinary frequency); they are most common in women aged 30–40 but can occur at any age.

Treatment options range from conservative management (watchful waiting, pharmacologic therapy) to procedural interventions (endometrial ablation, LNG-IUD, uterine artery embolization, MRgFUS) and hysterectomy when symptoms are not controlled by conservative therapy.

Scope of evidence covered: the policy summarizes comparative effectiveness, fertility, and safety evidence for LNG-IUD (multiple systematic reviews and RCT data supporting efficacy for heavy menstrual bleeding), endometrial ablation, UAE (evidence showing efficacy for symptom relief but limited/insufficient data on fertility preservation and mixed reintervention outcomes), and MRgFUS (insufficient/limited long-term evidence with variable outcomes and higher reintervention rates in some comparisons).

Evidence Item	Key Finding
InterQual references (policy reliance)	Endometrial ablation and UAE medical necessity determinations rely on InterQual CP modules for specific clinical criteria (policy directs to InterQual criteria).
Cochrane / Systematic reviews (LNG-IUD)	Cochrane and multiple systematic reviews show LNG-IUD is the most effective first-line non-surgical treatment to reduce menstrual blood loss and improves QOL versus medical therapy; superior short- and medium-term clinical response versus oral medical treatments.
NPVR comparative finding (MR-HIFU vs US-HIFU)	NPVR: MR-HIFU 58.92% vs US-HIFU 81.07%; NPVR >80% considered successful.
Fibroid volume reduction pooled numbers (Taheri et al. 2019)	Pooled fibroid volume reduction at 6 months: RFA 70%, UAE 54%, FUS 32%.
Barnard et al. (2017) randomized trial (UAE vs focused ultrasound)	UAE associated with higher immediate postprocedure pain, greater outpatient opioid/NSAID use and longer recovery (median days off work 8 vs 4) versus focused ultrasound; no difference in adverse event rates.
ECRI assessment for ExAblate (MRgFUS)	ECRI concluded evidence for the ExAblate Body System is inconclusive: suggests symptom reduction up to 3 years but studies have high risk of bias, small samples, and limited outcomes.

Definitions

Abnormal uterine bleeding (AUB)Any change in menstrual frequency or duration, amount of flow, or bleeding between cycles; postmenopausal bleeding = vaginal bleeding ≥12 months after cessation of menstruation or unpredictable bleeding on long-term hormone therapy.

MenorrhagiaBleeding occurs at normal intervals but with heavy flow or duration of more than seven days.

NPVR (Nonperfused Volume Ratio)Proportion of fibroid volume that is nonperfused after ablation; >80% considered successful.

MRgFUS / ExAblateMagnetic resonance-guided focused ultrasound ablation; noninvasive thermal ablation using MR guidance. ExAblate Body System has FDA PMA indication for ablation of uterine fibroid tissue under labeled conditions.

Note on MRgFUS NPVR dataMR-HIFU NPVR reported 58.92% vs US-HIFU 81.07%; NPVR >80% considered successful.

Revision History

11/01/2025material_changeLatest

Medical records documentation language added for reviews: clarified that benefit coverage is determined by federal/state/contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria; specified required contents (relevant history, physical exam, diagnostic test/procedure results), legibility, and availability upon request.

11/01/2025clinical_evidence_updateLatest

Clinical Evidence and References sections updated to reflect most current information; prior policy version CS002KY.09 archived.

Clinical guidance and coverage-relevant conclusions

Summarized societal guidance and evidence considerations that inform coverage decisions:

ACOG - LNG-IUD for bleeding: ACOG: LNG-IUD may be considered for treatment of abnormal uterine bleeding; insufficient evidence for other fibroid symptoms.

ACOG practice bulletin statements referenced.

ACOG - Endometrial sampling: ACOG: Office endometrial biopsy is first-line tissue sampling for evaluation of AUB; perform in individuals <45 years for persistent AUB/failed medical management.

ACOG practice bulletin and committee opinion referenced.

ACOG - UAE and counseling: ACOG: UAE recommended as a procedure for uterine leiomyomas in women desiring uterine preservation; counsel on limited reproductive outcome data.

ACOG practice bulletin recommends counseling on limited fertility data.

ACOG - MRgFUS comparative findings: ACOG: MRgFUS associated with reduction in leiomyoma and uterine size but less symptom improvement and higher reintervention vs UAE; data limited.

ACOG practice bulletin comparison cited.

AAGL - Embolic/ablative therapies and fertility: AAGL: Embolic and ablative therapies (including UAE, RFA, cryotherapy, MRgFUS) are not appropriate for women with submucous myomas who have current infertility or who wish to conceive.

AAGL position statement cited.

ACR - Appropriateness (2023): ACR: For reproductive-age symptomatic fibroids, laparoscopic/open myomectomy, medical management, MRgFUS, or UAE are usually appropriate initial therapies; medical management should usually be tried first.

ACR Appropriateness Criteria 2023 summarized.

NICE - MRgFUS/HIFU special arrangements: NICE: Ultrasound-guided HIFU and MRgFUS—use only with special arrangements for governance, consent, audit or research; inform patients of uncertain efficacy and fertility effects.

NICE guidance recommends specialized arrangements and informed consent.

SIR - UAE indications: SIR: UAE indicated for symptomatic uterine leiomyomata causing significant symptoms (HMB, pain/cramping, pressure, urinary symptoms, hydronephrosis).

SIR quality improvement guidelines enumerate common symptomatic indications for UAE.