ModifiedUnitedHealthcarePolicy CS002ID.B

Abnormal Uterine Bleeding and Uterine Fibroids (for Idaho Only)

Coverage and medical necessity guidance for treatments of abnormal uterine bleeding and uterine fibroids for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyAbnormal Uterine Bleeding and Uterine Fibroids (for Idaho Only)

Policy CodePolicy CS002ID.B

Change TypeDocumentation requirement addedarchival of prior version

Effective DateApr 1, 2026

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Added language specifying that the patient's medical record must contain documentation that fully supports the medical necessity for requested services, including history, physical exam, and diagnostic test results.

Removed reference link to the guidelines titled 'Medical Records Documentation Used for Reviews'.

Archived previous policy version CS002ID.A.

State-specificpolicy applies only to Idaho

Multipleprocedures and device codes listed

Evidence reviews citedsupporting clinical evidence discussed

71-95%

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reduction in menstrual bleeding reported with LNG-IUS

1%→29%reintervention rates after HIFU

30.5%reintervention rate after MRgFUS

Coverage and Medical Necessity Criteria

Uterine Fibroids (UAE, MRgFUS)

Covered when ALL of the following are met:

ALL of the following

Individual has symptomatic uterine fibroids documented by imaging (ultrasound, MRI) or clinical exam;
Symptoms include heavy menstrual bleeding, bulk-related symptoms (eg, pelvic pain, pressure, urinary frequency), or other clinically significant fibroid-related morbidity;
Individual is an appropriate candidate for a uterine-sparing procedure determined by treating clinician and multidisciplinary evaluation;
ONE of the following procedure-specific indications
- Uterine artery embolization (UAE) — indicated for symptomatic uterine fibroids when uterus-sparing therapy is desired and the individual has clinically documented fibroids and fibroid-related symptoms; refer to InterQual® CP: Procedures, Uterine Artery Embolization (UAE) for detailed medical necessity criteria;
  See evidence summary and fertility considerations below.
- Magnetic resonance-guided focused ultrasound ablation (MRgFUS) — considered only when selection criteria are met and when performed in context of shared decision-making and clinical governance; refer to MRgFUS indications and limitations described below;
  MRgFUS is considered investigational/unproven for routine coverage due to insufficient high-quality evidence on long-term symptom durability and comparative effectiveness.

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

Covered when ALL of the following are met:

ALL of the following

Individual has heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) attributable to endometrial dysfunction or fibroids where LNG-IUD is an appropriate therapeutic option;
LNG-IUD (eg, Mirena, Skyla, Liletta, Kyleena) is being used for treatment of menorrhagia or HMB for symptom control, quality of life improvement, or as an alternative to surgery;
Contraindications to LNG-IUD have been assessed and ruled out per usual clinical standards (eg, pregnancy, active pelvic infection, uterine cavity distortion incompatible with device placement);
Device placement and follow-up are performed by qualified providers and documented in the medical record.

Uterine-sparing procedures — Conditional Coverage Considerations

Conditional coverage and counseling considerations for uterine-sparing procedures (UAE, HIFU/MRgFUS):

ALL of the following

Individuals desiring future fertility must receive comprehensive counseling about uncertain and potentially adverse reproductive outcomes after UAE and MRgFUS, including possible reduced pregnancy rates, increased miscarriage risk, placenta previa, and postpartum hemorrhage as reported in the literature;
UAE is covered for symptomatic fibroids when medical management is inadequate, contraindicated, or declined, and when the treating clinician documents that UAE is an appropriate uterine-sparing option after discussion of alternatives including myomectomy and hysterectomy;
UAE is NOT covered when the sole intent is preservation of childbearing potential without full informed consent about limited and conflicting evidence regarding fertility outcomes;
MRgFUS — considered investigational or not medically necessary for routine coverage due to limited, low-quality, or inconsistent evidence regarding long-term symptom relief and comparative effectiveness unless provided under a documented clinical trial or registry or when local coverage policies explicitly allow with governance and informed consent;

Uterine Artery Embolization (UAE) Indications

Uterine Artery Embolization (UAE) — Indications and medical necessity logic:

ALL of the following

Documented symptomatic uterine fibroids with imaging confirmation and clinical correlation;
Symptoms include heavy menstrual bleeding or bulk-related symptoms that are clinically significant and have not responded to or are not candidates for medical management (unless medical management is contraindicated or declined);
Individual desires uterus-sparing therapy or is a candidate for a less invasive approach compared with hysterectomy;
Provider documents discussion of alternative treatments (medical therapy, myomectomy, hysterectomy, endometrial ablation when appropriate), risks (including reproductive risks), and expected outcomes;

MR-guided Focused Ultrasound (MRgFUS) Indications

MR-guided Focused Ultrasound (MRgFUS) — Indications, limitations, and coverage stance:

ALL of the following

MRgFUS may be considered only when the individual meets strict selection criteria (eg, fibroid number, size, location, MRI characteristics such as T2 signal and non-perfused volume expectations) and when standard therapies are contraindicated, declined, or when performed within a research protocol or registry that captures long-term outcomes;
Routine coverage for MRgFUS is not supported due to insufficient high-quality evidence demonstrating durable symptom relief and favorable comparative effectiveness versus established alternatives (eg, myomectomy, UAE);
When MRgFUS is pursued, providers must document that alternative treatments were discussed, that the patient received counseling on the higher reintervention rates reported in some comparative studies, and that consent included discussion of uncertainties regarding pregnancy and long-term outcomes;
MRgFUS may be performed under systems of clinical governance and audit consistent with NICE guidance when local policy allows and appropriate informed consent is obtained.

Levonorgestrel-Releasing IUDs (LNG-IUD)

Levonorgestrel-Releasing IUDs (LNG-IUD) — Evidence-supported uses and operational notes:

ALL of the following

LNG-IUDs (eg, Mirena, Skyla, Liletta, Kyleena) are proven and medically necessary for treatment of menorrhagia/HMB and are an appropriate first-line or alternative therapy to systemic medical treatments for many individuals;
Placement is medically necessary when indicated for symptom control, as documented by clinician assessment and prior treatment history where applicable;
Contraindications and device-specific labeling should be followed; for informational purposes FDA approvals or labeling do not alone determine coverage decisions;
Providers should document counseling on device risks, benefits, alternatives, and follow-up care in the medical record.

Coding and Device Information

Uterine fibroids / procedural CPT and Category IIImixed

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 DeviceHCPCSCovered

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 approvals (informational)mixed

No codes listed

inv-21: Uterine size limit (historical)

Historical uterine size restrictionExAblate PMA originally indicated treatment for uterine fibroids when uterine size was less than 24 weeks.

PMA labeling updateExAblate 2000/2100 PMA received on Oct 22, 2004 with updated labeling on Aug 9, 2011 indicating uterine-sparing use for symptomatic fibroids.

Childbearing restriction removed (2015)On Aug 31, 2015 the PMA indications were modified to remove the requirement that women have completed childbearing.

Prior Authorization, Documentation, and Clinical Governance

Prior Authorization

InterQual-based prior authorization

InterQual-based prior authorization — coverage when InterQual criteria met. Providers should obtain prior authorization when required; services that meet InterQual clinical criteria will be considered medically necessary.

Refer to InterQual® CP modules (e.g., Hysteroscopy, Operative; Uterine Artery Embolization) for specific clinical coverage criteria.
Prior authorization may be required per member benefit; verify plan-specific requirements prior to scheduling.

Prior Authorization

Prior authorization recommended for UAE and MRgFUS/HIFU

Prior authorization recommended for UAE and MRgFUS/HIFU — procedures with limited or mixed evidence. Because evidence for fertility preservation and long-term outcomes is uncertain, careful case selection and prior authorization are advised.

Uterine artery embolization (UAE) and MRgFUS/HIFU often require specialty review prior to approval.
Document discussions about fertility preservation risks and alternatives when fertility is a concern.

Clinical Background and Scope

Abnormal uterine bleeding (AUB) refers to any change in menstrual frequency, duration, amount of flow, or bleeding between cycles and includes patterns such as menorrhagia and metrorrhagia. Uterine fibroids (leiomyomata) are benign tumors that commonly present in reproductive‑age individuals and may cause heavy bleeding, uterine enlargement and bulk‑related symptoms such as pelvic pain and pressure. Treatment options range from conservative medical therapy (including levonorgestrel‑releasing IUDs) to minimally invasive uterine‑sparing procedures and hysterectomy for refractory or severe disease; patient symptoms, fertility desires, and evidence for effectiveness guide therapy selection.

Definitions and Abbreviations

inv-39: Definition — Abnormal uterine bleeding (AUB)

Core definitionAny change in menstrual period frequency or duration, change in amount of flow, or bleeding between cycles; includes oligomenorrhea, polymenorrhea, menorrhagia, menometrorrhagia, and metrorrhagia.

Postmenopausal AUBVaginal bleeding 12 months or more after cessation of menstruation, or unpredictable bleeding in those on hormone therapy for 12 months or more.

Common associated causesMay be idiopathic or associated with fibroids, polyps, pelvic pathology, anatomical abnormalities, systemic illness, hormonal imbalance, or medications.

inv-40: Definition — Uterine fibroids (leiomyomata)

TermUterine fibroids (leiomyomata)

Description

Policy Revision History

2026-04-01policy_revisionLatest

Added explicit documentation requirements specifying that the patient’s medical record must contain documentation that fully supports medical necessity (including history, physical exam, and pertinent diagnostic test/procedure results), that records be legible and made available upon request; removed a reference link to the 'Medical Records Documentation Used for Reviews' guidelines; archived previous policy version CS002ID.A.

Policy Summary

PayerUnitedHealthcare

PolicyAbnormal Uterine Bleeding and Uterine Fibroids (for Idaho Only)

Policy CodePolicy CS002ID.B

Change TypeDocumentation requirement addedarchival of prior version

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

Shared decision-making documentation should include patient goals (symptom relief, uterus preservation, fertility desires), discussion of risks/benefits, alternative treatments, and fertility implications when applicable.

No contraindications to UAE (eg, active pelvic infection, uncorrected coagulopathy, pregnancy, suspected uterine malignancy);

Pre-procedure evaluation includes endometrial sampling when indicated to exclude malignancy, and appropriate imaging and laboratory assessment.

Note

Special arrangements and informed consent

Special arrangements and informed consent — for procedures with limited evidence, follow clinical governance and obtain informed consent that documents risks, uncertainties, and alternatives.

Use documented shared decision-making and provide written information on uncertainties of efficacy and fertility impact.
Consider audit, research enrollment, or multidisciplinary review when local governance recommends special arrangements.

Prior Authorization

Verify benefit and documentation requirements

Verify benefit and documentation requirements — providers must confirm member benefits and any prior authorization or third‑party tool use before performing services.

Check member-specific plan language for coverage, prior authorization, and any precertification portals.
UnitedHealthcare may use InterQual® or other third‑party tools to assist in benefit determinations.

Step Therapy

Conservative therapy before procedures

Conservative therapy before procedures — initial management for AUB should prioritize watchful waiting and pharmacologic therapy; LNG‑IUD is an identified effective non‑surgical option.

Document trials of conservative measures (e.g., NSAIDs, antifibrinolytics, hormonal therapy) when applicable.
LNG‑IUD (e.g., Mirena®, Skyla®, Liletta®, Kyleena™) is an effective first‑line non‑surgical option for heavy menstrual bleeding and should be considered before invasive procedures in appropriate patients.

Documentation Required

LNG‑IUS as first‑line for non‑surgical candidates

LNG‑IUS as first-line for non-surgical candidates — guideline-level evidence supports using levonorgestrel‑releasing intrauterine systems as the preferred initial medical therapy for heavy menstrual bleeding when surgery is not planned or the patient seeks non‑surgical treatment.

Document patient counseling about LNG‑IUS benefits, alternatives, and potential adverse effects.
If LNG‑IUS is declined or unsuccessful, document reasons and prior treatments before requesting authorization for invasive procedures.

Step Therapy

Trial of medical management first

Trial of medical management first — guidelines recommend a trial of medical therapy before invasive treatments; MRgFUS is among alternative options and may have higher reintervention rates.

Document duration and response to medical therapy prior to procedural requests.
Discuss and document fertility desires and how they influence treatment choice.

Documentation Required

Medical records documentation used for reviews

Medical record requirements — documentation must fully support medical necessity. Lack of adequate documentation (history, exam, diagnostic tests, prior treatments, and informed consent) may result in denial or non‑coverage.

Include relevant medical history, physical exam findings, imaging reports, laboratory or endometrial sampling results, and prior treatment attempts.
Maintain legible records and make them available upon request; insufficient documentation may lead to claim denial.

Documentation Required

Document counseling and prior treatments

Document counseling and prior treatments — record symptom severity, prior therapies (medical and procedural), fertility desires, and risks/benefits discussions when seeking authorization for invasive procedures.

Capture objective measures of bleeding impact (e.g., hemoglobin, transfusion history, validated patient‑reported outcomes) where available.
Document why non‑surgical options (including LNG‑IUS) were unsuitable or declined if proceeding to procedural interventions.

Documentation Required

Preoperative evaluation and consent

Preoperative evaluation and consent — perform appropriate imaging and cancer risk assessment before procedures that may disseminate tissue; ensure endometrial sampling and cervical screening per guidelines.

Assess malignancy risk with imaging and endometrial evaluation prior to morcellation or tissue‑extracting procedures.
Document informed consent that includes discussion of potential dissemination of occult malignancy and alternative approaches.

Denial Risk

Medical records documentation requirement

Medical records documentation requirement — reinforce that member medical records must support medical necessity; missing or unclear documentation increases the risk of authorization denial.

Ensure all diagnostic data, treatment timelines, and shared decision‑making notes are present in the chart.
Requests lacking adequate information may be returned for more information or denied.

Benign tumors of the uterus with a rich blood supply that may cause excessive uterine bleeding, uterine enlargement, and bulk-related symptoms such as pelvic pain, pressure, urinary frequency, and abdominal distension.

Epidemiology noteMost commonly found in women aged 30-40 years but can occur at any age.

inv-41: Definition — LNG-IUS / LNG-IUD (device description)

Device/termLevonorgestrel-releasing intrauterine system (LNG-IUS / LNG-IUD)

Drug content and releaseContains 52 mg levonorgestrel releasing approximately 20 µg/day during the first year.

Clinical useUsed to reduce menstrual blood loss and treat heavy menstrual bleeding (HMB); evaluated in RCTs showing superior short- and medium-term outcomes vs medical therapy.

inv-42: Definition — HIFU / MRgFUS explanation

TermHigh-intensity focused ultrasound (HIFU) / Magnetic resonance-guided focused ultrasound (MRgFUS)

TechniqueNoninvasive thermal ablation of uterine fibroids performed under ultrasound guidance (USgHIFU) or magnetic resonance guidance (MRgFUS/MR-HIFU).

Evidence/limitationsEvidence shows fibroid shrinkage but long-term durability and standardized protocols are limited; MRgFUS may have longer treatment times and variable NPVR compared with USgHIFU.

inv-43: Definition — UAE / UFE description

TermUterine artery embolization (UAE) / uterine fibroid embolization (UFE)

DescriptionMinimally invasive radiologic procedure to devascularize fibroids by embolizing uterine arteries to reduce fibroid size and symptoms; alternative to hysterectomy in selected patients.

Preprocedure recommendationEndometrial biopsy is recommended prior to UFE to rule out malignancy or hyperplasia.

inv-44: Definition — NPVR (Non‑Perfused Volume Ratio) and success threshold

AcronymNPVR — Non‑Perfused Volume Ratio

DefinitionProportion of fibroid volume rendered nonperfused after ablation (measured postprocedure).

Success thresholdAn NPVR greater than 80% is considered successful; subgroup analyses note NPVR ≥50% associates with lower reintervention rates.

inv-45: Definition — Funaki type (MRI T2 classification) used for MR-HIFU eligibility

TermFunaki classification (MRI T2 signal)

UseMRI T2 signal–based categorization of fibroids used to determine MR-HIFU eligibility; high T2 signal (Funaki type 3) is often excluded from MR‑HIFU candidacy.

Evidence noteStudies excluded Funaki type 3 fibroids from MR-HIFU analyses due to lower expected treatment success or higher risk of inadequate treatment.

inv-46: Definition — Symptomatic uterine leiomyomata (list of symptoms)

Symptom domainSymptomatic uterine leiomyomata — heavy or prolonged menstrual bleeding

Other symptomsSevere menstrual cramping; pelvic pressure, discomfort, bloating, or abdominal distortion from enlarged uterus; pelvic pain including dyspareunia.

Additional manifestationsUrinary urgency, frequency, nocturia or retention related to enlarged uterus; hydronephrosis caused by the enlarged uterus.

inv-47: Definition — Laparoscopic power morcellator and FDA safety communication

DeviceLaparoscopic power morcellator

FunctionClass II device used in minimally invasive gynecologic surgeries to fragment tissue so it can be removed through small incisions.

FDA safety communicationFDA warns morcellation may spread unsuspected cancer; manufacturers should include a black box warning and contraindications. Morcellators are contraindicated when tissue is known or suspected to contain malignancy and contraindicated in peri- or post-menopausal patients or when en bloc removal is possible.