CurrentUnitedHealthcarePolicy MMP098.10

Uterine Services and Procedures

Medicare Advantage policy governing coverage guidance and coding reference for uterine procedures including uterine artery embolization (UAE) for fibroids, MRI‑guided focused ultrasound ablation, and hysterectomy; intended for UnitedHealthcare Medicare Advantage providers and adjudicators.

Policy Summary

PayerUnitedHealthcare

PolicyUterine Services and Procedures

Policy CodePolicy MMP098.10

Change TypeRevisions to hysterectomy languagereferences and archival added

Effective DateOct 1, 2025

Next Review Date

Key ActionFollow UnitedHealthcare Medicare Advantage plan and delegate requirements for utilization management and any applicable prior authorization processes for the listed procedure codes.

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: refer to that policy for all other indications not listed in the NCD for Sterilization (NCD 230.3).

Added References section and archived previous policy version MMP098.09.

3procedure categories

manyhysterectomy codes

10/01/2025effective

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Coverage Criteria for Uterine Procedures

UAE and MRI‑guided focused ultrasound coverage

Covered when criteria from referenced UnitedHealthcare Commercial Medical Policies and general Medicare guidelines are met

UAE coverage logic: Uterine artery embolization (UAE) for treatment of uterine fibroids or severe dysfunctional uterine bleeding is considered reasonable and necessary when the patient meets the criteria in the UnitedHealthcare Commercial Medical Policy referenced in this document and general Medicare guidelines where applicable.

Provider must use the referenced UnitedHealthcare Commercial Medical Policy to supplement Medicare guidance to determine medical necessity.

MRI-guided focused ultrasound coverage: Magnetic resonance imaging (MRI)-guided focused ultrasound ablation for uterine fibroids is considered under the same approach: refer to the UnitedHealthcare Commercial Medical Policy titled Abnormal Uterine Bleeding and Uterine Fibroids for specific coverage criteria; Medicare has no specific NCD for MRI-guided procedures.

Use the commercial policy criteria to supplement general Medicare guidance when determining medical necessity for MRI-guided focused ultrasound.

Hysterectomy

Hysterectomy coverage guidance

Hysterectomy guidance: Medicare does not have an NCD for hysterectomy for benign conditions; for indications not listed in the NCD for Sterilization (NCD 230.3), refer to the UnitedHealthcare Commercial Medical Policy titled Hysterectomy for coverage guidelines.

Elective hysterectomy or tubal ligation when the primary indication is sterilization is nationally non-covered per NCD for Sterilization (230.3).

Elective hysterectomy or tubal ligation performed primarily for sterilization is nationally non‑covered under the Medicare National Coverage Determination for Sterilization (NCD 230.3). Medicare does not have a National Coverage Determination for hysterectomy for benign conditions; for indications other than sterilization, refer to the UnitedHealthcare Commercial Medical Policy titled Hysterectomy for coverage guidance.

The policy uses referenced UnitedHealthcare Commercial Medical Policy criteria to supplement general Medicare guidance for uterine artery embolization (UAE) and related procedures. Applying those criteria consistently helps avoid both inappropriate denials and inappropriate approvals. If the referenced criteria are not applied during review, there is an increased risk that a service that is actually reasonable and necessary could be denied, or that an inappropriate approval could occur.

Coding — CPT and Procedure Codes

UAE for Uterine FibroidsCPT

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 AblationCPT

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 codesCPT

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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Focused ultrasound leiomyomata volume threshold — coding

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 threshold summaryDistinguish procedure coding by total leiomyomata volume: <200 cc use 0071T; ≥200 cc use 0072T.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization / Utilization Management

Prior authorization and utilization management requirements vary by plan. Follow the UnitedHealthcare Medicare Advantage plan and any delegated organization’s prior authorization and utilization management requirements for services related to Uterine Artery Embolization (UAE).

If a delegate manages utilization management or prior authorization for a member’s Medicare Advantage plan, the delegate’s requirements must be followed.

Note

Documentation Required

Documentation and Claims Responsibility

Providers must retain or have access to appropriate clinical documentation to support medical necessity and coverage of UAE when requested. UnitedHealthcare Medicare Advantage Policies use CPT, CMS, and other coding guidelines for processing claims; references are for definitional purposes and do not guarantee reimbursement. Providers are responsible for submission of accurate claims and for following member-specific benefit plan documents.

Background and Clinical Context

Uterine fibroids (leiomyomata) are benign smooth‑muscle tumors that can cause heavy menstrual bleeding, pelvic pain, and compressive symptoms. Uterine artery embolization (UAE) and MRI‑guided focused ultrasound ablation are minimally invasive, uterus‑sparing alternatives to hysterectomy for selected patients. Each procedure carries specific risks: UAE can result in postembolization syndrome — a constellation of symptoms including pelvic pain, cramping, vaginal discharge, nausea, vomiting, fatigue, and general discomfort — and both procedures carry risks of hemorrhage, infection, injury to adjacent structures, and procedure‑related complications. These risks and benefits should be weighed when determining medical necessity and selecting the appropriate treatment.

Definitions

Postembolization syndrome — definition and symptoms

DefinitionA constellation of symptoms occurring after uterine artery embolization (postembolization syndrome).

Common symptomsPelvic pain and cramping; vaginal discharge; nausea and vomiting; fatigue and general discomfort.

Clinical contextMay follow UAE and is noted as a potential procedure-specific risk in discussions of benefits and harms.