CurrentUnitedHealthcarePolicy CS002ID.C

Abnormal Uterine Bleeding and Uterine Fibroids (for Idaho Only)

State-specific UnitedHealthcare medical policy for Idaho (including Idaho Medicaid Plus) addressing coverage and medical necessity of endometrial ablation, levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), and magnetic resonance-guided focused ultrasound ablation (MRgFUS) for abnormal uterine bleeding and uterine fibroids, including referenced criteria via InterQual.

Policy Summary

PayerUnitedHealthcare

PolicyAbnormal Uterine Bleeding and Uterine Fibroids (for Idaho Only)

Policy CodePolicy CS002ID.C

Change TypeSupporting information updated

Effective DateMay 1, 2026

Next Review Date

Key ActionDocument and maintain medical record evidence supporting medical necessity and ensure InterQual criteria are met and recorded for endometrial ablation and UAE.

POLICY UPDATE CHANGES

05/01/2026 - Updated Clinical Evidence and References sections to reflect the most current information; archived previous policy version CS002ID.B

4Procedures addressed (endometrial ablation, LNG-IUD, UAE, MRgFUS)

1State-specific policy (Idaho only)

NPVR >80%Success threshold (HIFU)

70%RFA 6-month fibroid volume reduction (pooled)

UAE 6-month fibroid volume reduction (pooled)

32%FUS 6-month fibroid volume reduction (pooled)

Coverage Summary

This Idaho-specific UnitedHealthcare coverage policy (effective 05/01/2026) addresses abnormal uterine bleeding (AUB) and uterine fibroids and the medical necessity/coverage stance for several minimally invasive procedures: endometrial ablation (covered when InterQual hysteroscopy operative criteria are met), levonorgestrel-releasing intrauterine devices (LNG-IUDs) (covered for menorrhagia per FDA/clinical guidance), uterine artery embolization (UAE) (covered for symptomatic fibroids and related bleeding with InterQual UAE criteria; not covered when intended to preserve childbearing potential), and magnetic resonance-guided focused ultrasound ablation (MRgFUS) (considered unproven and not medically necessary).

Quick policy thresholds and facts

NPVR success threshold> 80% considered successful

ExAblate uterine size indicationUterine size less than 24 weeks (ExAblate PMA)

LNG-IUS vs UAE size notesNICE: LNG-IUS first-line for fibroids < 3 cm; UAE listed as option for fibroids >= 3 cm (assess with ultrasound/MRI)

Procedures addressed (quick fact)Four procedures/topics addressed: endometrial ablation, LNG-IUD, UAE, MRgFUS

Medical Necessity Criteria

Endometrial Ablation

Covered when meeting InterQual CP: Procedures, Hysteroscopy, Operative criteria

Endometrial Ablation: Endometrial ablation is proven and medically necessary for treating abnormal uterine bleeding in premenopausal individuals.

For medical necessity clinical coverage criteria: refer to InterQual® CP: Procedures, Hysteroscopy, Operative.

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

Covered when indicated for menorrhagia and per FDA labeling; clinical detail and evidence summarized in policy

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD): LNG-IUDs (e.g., Mirena, Skyla, Liletta, Kyleena) are proven and medically necessary for treating menorrhagia.

Refer to the FDA section for additional device-specific approval information.

Clinical Conclusions, Comparative Findings and Guideline Positions

Clinical conclusions and comparative findings

Summarized evidence statements and guideline positions:

Volume reduction comparisons (Taheri et al. 2019): RFA pooled fibroid volume reduction at 6 months: 70%; UAE pooled fibroid volume reduction at 6 months: 54%; FUS pooled fibroid volume reduction at 6 months: 32%.
Taheri et al. 2019 pooled reductions.
MR-HIFU vs US-HIFU (Yu et al. 2021): MR-HIFU had lower NPVR (58.92%) compared to US-HIFU (81.07%); NPVR > 80% considered successful; MR-HIFU treatment time nearly double US-HIFU (US mean 96.9 minutes).
Periprocedural outcomes (Barnard et al. 2017): Focused ultrasound had longer procedure time; UAE associated with higher immediate postprocedure pain, greater outpatient opioid/NSAID use, and longer recovery (days off work 8 vs 4; return to normal 15 vs 10); no difference in incidence/severity of adverse events.

FDA & Device Regulatory Information

FDA / Device regulatory information

Regulatory approvals and warnings:

FDA / Device regulatory information: ExAblate 2000/2100 System (Insightec) PMA approved Oct 22, 2004; labeling updated Aug 9, 2011; indicated for ablation of uterine fibroid tissue in pre- or perimenopausal women with symptomatic fibroids and uterine size < 24 weeks; Aug 31, 2015 modification removed restriction to women who had completed childbearing.

LNG-IUD approvals: Mirena FDA approval Dec 8, 2000; HMB indication Oct 1, 2009; Skyla Jan 9, 2013; Liletta Feb 26, 2015; Kyleena Sep 16, 2016.

UAE regulatory status: UAE is a procedure and therefore not subject to FDA device regulation; embolic agents used are subject to FDA oversight.

FDA safety communication on morcellation:

Coding (reference lists)

Uterine Fibroids / Procedure Codes (reference list)CPT|HCPCS

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...; for tumors, organ ischemia, or infarction.
58563	Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation).

Levonorgestrel-Releasing Intrauterine Device (drug/device) codesHCPCS|CPT|J|S

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.

Provider Actions & Requirements

Documentation Required

Medical record documentation requirement

The patient's medical record must contain documentation that fully supports medical necessity for the requested service, including relevant history, physical exam, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the patient's medical record, and made available upon request to support reviews and coverage decisions.

Prior Authorization

InterQual criteria reference for medical necessity

Medical necessity determinations for endometrial ablation and uterine artery embolization reference InterQual® CP criteria. Providers should obtain and document that the applicable InterQual criteria are met when submitting requests for coverage or prior authorization.

Definitions

Definitions (term = definition)

Abnormal Uterine Bleeding (AUB)Any change in menstrual frequency, duration, amount of flow, or bleeding between cycles; in postmenopausal women bleeding 12+ months after cessation

NPVRNonperfused Volume Ratio — measure of ablated fibroid volume; >80% considered successful

MRgFUS / MR-HIFUMagnetic Resonance–guided Focused Ultrasound Ablation / Magnetic Resonance High-Intensity Focused Ultrasound — MR-guided thermal ablation of fibroids

US-HIFU / FUSUltrasound-guided High-Intensity Focused Ultrasound / Focused Ultrasound Surgery — ultrasound-guided thermal ablation of fibroids

UAEUterine Artery Embolization — injection of particles via uterine arteries to block blood supply to fibroids causing shrinkage

RFARadiofrequency Ablation — percutaneous or transcervical application of radiofrequency energy to ablate fibroid tissue

Revision History

05/01/2026revisedLatest

05/01/2026 - Updated Clinical Evidence and References sections to reflect the most current information; archived previous policy version CS002ID.B

Policy Summary

PayerUnitedHealthcare

PolicyAbnormal Uterine Bleeding and Uterine Fibroids (for Idaho Only)

Policy CodePolicy CS002ID.C

Change TypeSupporting information updated

Effective DateMay 1, 2026

Next Review Date

Key ActionDocument and maintain medical record evidence supporting medical necessity and ensure InterQual criteria are met and recorded for endometrial ablation and UAE.

On This Page

Uterine Artery Embolization (UAE)

Covered for specific symptomatic indications; limitations noted

Uterine Artery Embolization (UAE): UAE is proven and medically necessary for treating symptomatic uterine fibroids, postpartum or post hysterectomy bleeding, or uterine arteriovenous malformation (AVM).

For medical necessity clinical coverage criteria: refer to InterQual® CP: Procedures, Uterine Artery Embolization (UAE). 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.

Magnetic Resonance-Guided Focused Ultrasound Ablation (MRgFUS)

Not covered — evidence insufficient

Magnetic Resonance-Guided Focused Ultrasound Ablation (MRgFUS): MRgFUS is unproven and not medically necessary for treating uterine fibroids due to insufficient evidence of efficacy.

Evidence limited by small, biased studies and lack of long-term outcomes; see cited systematic reviews and evidence assessments.

Evidence assessments: ECRI and Hayes concluded evidence for MRgFUS/ExAblate inconclusive or low-quality; suggest symptom and QOL improvements up to 3 years but high risk of bias and limited outcomes.

Guideline positions (recommendations and cautions)

Professional society positions summarized:

AAGL (2012): Embolic and ablative therapies (UAE, occlusion, RFA, cryotherapy, MRgFUS) are not appropriate for women with submucous myomas who have current infertility or who wish to conceive (Level C).
ACOG positions: Preoperative evaluation and risk stratification prior to morcellation; inform patients about dissemination risk; LNG-IUD may be considered for abnormal uterine bleeding but insufficient evidence for other fibroid symptoms; surgical management for acute AUB when unstable or failed medical management.
NICE recommendations: Ultrasound-guided HIFU and MRgFUS should be used only with special arrangements for governance, consent, audit or research; LNG-IUS recommended as first treatment for certain HMB scenarios; UAE an option for fibroids ≥ 3 cm with imaging assessment prior to procedure.
ACR (2023): Laparoscopic/open myomectomy, medical management, MRgFUS, or UAE usually appropriate as initial therapy for reproductive-age patients wishing fertility preservation; medical management should usually be tried first and procedures performed by trained clinicians.
SIR (2014): UAE indicated for uterine leiomyomata causing significant symptoms (lists common symptoms).

Abnormal uterine bleeding (AUB) includes changes in cycle frequency, duration, amount of flow, or bleeding between cycles; conservative management options include watchful waiting, pharmacotherapy (hormonal therapy), dilation and curettage, and hysterectomy when conservative measures fail. For uterine fibroids, ACOG and the policy recommend preprocedural assessment including an endometrial biopsy prior to uterine fibroid embolization (UFE/UAE) to rule out malignancy or hyperplasia. Minimally invasive alternatives summarized in the policy include LNG-IUD placement, endometrial ablation, uterine artery embolization, and focused ultrasound approaches, each with differing evidence, recovery profiles, and fertility considerations.

Supporting evidence and evidence sources cited in the policy:

- InterQual clinical criteria are referenced for determining medical necessity for endometrial ablation and UAE (proprietary external criteria).

- Systematic reviews and evidence assessments (ECRI; Hayes) conclude MRgFUS/HIFU evidence is limited or inconclusive with methodological limitations and uncertainty about long-term outcomes.

- Barnard et al. (2017) randomized trial found focused ultrasound procedures were longer, while UAE was associated with higher immediate postprocedure pain, greater outpatient opioid/NSAID use, and longer recovery despite similar adverse event rates.

- Taheri et al. (2019) pooled analyses reported 6-month fibroid volume reductions of RFA 70%, UAE 54%, and FUS 32%.

- Meta-analyses comparing MR-HIFU and US-HIFU report NPVR differences (MR-HIFU ~58.9% vs US-HIFU ~81.1%) and note NPVR > 80% is considered successful.

FDA Safety Communication (Nov 24, 2014) on laparoscopic power morcellators: black box warning advising against use in majority of women undergoing myomectomy/hysterectomy due to risk of spreading unsuspected cancer; contraindicated when tissue known/suspected malignancy or in peri/postmenopausal women or when en bloc removal feasible.

Documentation Required

Informed consent and patient counseling for morcellation and focused ultrasound

Inform patients about risks including possible dissemination of occult uterine malignancy with morcellation and the limited/uncertain efficacy and risks of MRgFUS/HIFU (for example, potential skin burns and uncertain effects on fertility). Document shared decision-making and obtain informed consent that records counseling on these risks and alternatives.

Prior Authorization

Use of MRgFUS / ultrasound-guided HIFU should include governance and audit processes

Use of MRgFUS and ultrasound-guided HIFU should be performed with special arrangements for clinical governance, consent, and audit (or as part of research). These procedures should be done in specialized centers by clinicians with specific training; local audit and review of clinical outcomes and governance processes are recommended.

Documentation Required

Pre-procedure assessment for UAE and other interventions

Pre-procedure assessment should include evaluation of uterine and fibroid size, position, number, and vascularity by ultrasound, and MRI if additional information is needed. For individuals with persistent AUB and age <45 years, perform endometrial sampling (office endometrial biopsy) prior to interventions to rule out malignancy or hyperplasia per ACOG guidance; document imaging and sampling results.

Denial Risk

Contraindication to morcellation

Laparoscopic power morcellators are contraindicated when uterine tissue is known or suspected to contain malignancy, in peri- or postmenopausal patients, or when en bloc removal is feasible. Failure to adhere to these contraindications may create clinical and regulatory risk and should be avoided and documented.