DESCRIPTION
Uterine fibroids (leiomyomata) are benign tumors of the uterus with a rich blood supply that can cause excessive bleeding, pain, possible infertility, and urinary symptoms, such as frequency. For women who no longer wish to maintain fertility, a hysterectomy is the primary treatment option of symptomatic or rapidly enlarging fibroids. Other options include myomectomy, hormonal therapy with gonadotropin-releasing hormone analogues and luteinizing-hormone releasing hormone analogues, or endurance until menopause when fibroids often regress.
Uterine artery embolization (UAE), also known as transcatheter UAE, is a treatment option used to promote shrinkage of symptomatic uterine fibroids by deprivation of blood supply. An interventional radiologist under fluoroscopic guidance performs UAE as a same day procedure. A catheter is first introduced through the femoral vasculature, then into the main arteries that supply the uterus. The radiologist injects contrast dye in order to visualize the vessels. Tiny balls made of plastic or gelatin sponge, the size of grains of sand, are injected through the catheter into the uterine artery on one side of the body. The balls block the blood supply to the fibroids. Without blood supply, the fibroids atrophy or infarct. The procedure is repeated on the other side of the body so the blood supply is blocked in both the right and left uterine arteries.
Recently, surgical occlusion of the uterine arteries using bipolar coagulation or endoclips has been investigated as an alternative to uterine artery embolization.
POLICY
Uterine artery embolization for the primary treatment of fibroids is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Repeat uterine artery embolization for the treatment of persistent symptoms of uterine fibroids after an initial uterine artery embolization is considered investigational.
Surgical occlusion of uterine arteries for the treatment of persistent symptoms of uterine fibroids is considered investigational.
MEDICAL APPROPRIATENESS
Uterine artery embolization for the primary treatment of fibroids is considered medically appropriate for ALL of the following:
When other causes (e.g., gastrointestinal or urological) have been evaluated and ruled out
Conservative medical treatment has failed
ANY ONE of the following
Asymptomatic fibroids of such size that they are palpable abdominally and are a concern to the individual
Fibroids deemed to be the cause of excessive uterine bleeding as evidenced by either profuse bleeding lasting more than eight (8) days or significant anemia (i.e., HCT less than 30%)
Fibroids deemed to be the cause of either acute severe pain or chronic lower abdominal pain
Fibroids deemed to be the cause of low back pressure or bladder pressure with urinary frequency
Is a poor candidate for the surgical treatment of fibroids
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
The American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice considers uterine artery embolization investigational or relatively contraindicated in women wishing to remain fertile. The Committee recommends that women considering uterine artery embolization have a thorough evaluation with an obstetrician-gynecologist, to help facilitate optimal collaboration with interventional radiologists, to help ensure the appropriateness of this therapy, and to consider the their own reproductive wishes.
No controlled studies were found in the published literature that validates the application of repeat uterine artery embolization for the treatment of persistent symptoms of uterine fibroids after an initial uterine artery embolization, or surgical occlusion of the uterine arteries.
SOURCES
Ambat, S., Mittal, S., Srivastava, D. N., Misra, R., Dadhwal, V., & Ghosh, B. (2009). Uterine artery embolization versus laparoscopic occlusion of uterine vessels for management of symptomatic uterine fibroids. International Journal of Gynaecology and Obstetrics, 105 (2), 162-165. (Level 2 Evidence - Independent study)
BlueCross BlueShield Association, Medical Policy Reference Manual. (1:2009). Occlusion of uterine arteries using transcatheter embolization or laparoscopic occlusion to treat uterine fibroids (4.01.11). Retrieved March 15, 2010 from BlueWeb. (25 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, November). Therapeutic embolization (NCD 20.28, p. 2-27). The Ingenix Complete Guide to Medicare Coverage Issues.
Edwards, R. D., Moss, J. G., Lumsden, M. A., Wu, O., Murray, L. S. Twaddle, S., et al. (2007). Uterine-artery embolization versus surgery for symptomatic uterine fibroids. The New England Journal of Medicine, 356 (4), 360-370. (Level 1 Evidence - Industry sponsored)
Gabriel-Cox, K., Jacobson, G. F., Armstrong, M. A., Hung, Y. Y., & Learman, L. A. (2007). Predictors of hysterectomy after uterine artery embolization for leiomyoma. American Journal of Obstetrics & Gynecology, 196 (6), 588.e1-e6. (Level 1 Evidence - Independent study)
Hald, K., Klow, N., Qvigstad, E., & Istre, O. (2007). Laparoscopic occlusion compared with embolization of uterine vessels: A randomized controlled trial. Obstetrics & Gynecology, 109 (1), 20-27. (Level 2 Evidence - Independent study)
Hayes. Medical Technology Directory. (2009, December). Uterine artery embolization. Retrieved March 15, 2010 from www.Hayesinc.com/subscribers. (128 articles and/or guidelines reviewed)
National Guideline Clearinghouse. (2006, December). Chronic abnormal uterine bleeding in nongravid women. Retrieved March 15, 2010 from http://www.guidelines.gov.
National Institute for Health and Clinical Excellence (NICE). (2004, November). Uterine artery embolisation for the treatment of fibroids. Retrieved March 15, 2010 from http://www.nice.org.uk/nicemedia/pdf/ip/IPG094guidance.pdf.
Park, A. J., Bohrer, J. C., Bradley, L. D., Diwadkar, G. B., Moon, E., Newman, J. S., et al. (2008). Incidence and risk factors for surgical intervention after uterine artery embolization. American Journal of Obstetrics & Gynecology, 199 (6), 671.e1-e6. (Level 2 Evidence - Independent study)
Society of Interventional Radiology. (2008, September). Fact sheet. Uterine fibroid embolization, a minimally invasive treatment for uterine fibroids. Retrieved March 15, 2010 from http://www.sirweb.org/news/newsPDF/facts/UFE_fact_sheet_09.pdf.
Technology Evaluation Center. (2002, August). Uterine artery embolization for treatment of symptomatic uterine fibroids (Vol. 17, No. 8). Chicago: BlueCross BlueShield Association. (32 articles and/or guidelines reviewed)
U. S. Food and Drug Administration (2002, November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K021397. Retrieved March 15, 2010 from http://www.accessdata.fda.gov/cdrh_docs/pdf2/K021397.pdf.
ORIGINAL EFFECTIVE DATE: 5/1/2000
MOST RECENT REVIEW DATE: 4/8/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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