58140
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
15.40
Facility
$812.98
Non-Facility
$812.98
Documentation Required
- Procedure-specific intra- and post-procedure documentation: procedural details, device used, non-perfused volume (NPV) measures when applicable, analgesia/pain control measures, and adverse events/complications, as reported in trials.
- Documented persistence of one or more symptoms directly attributable to uterine fibroids (examples required/acceptable: excessive menstrual bleeding/menorrhagia, bulk-related pelvic pain, pelvic pressure/discomfort, urinary symptoms from compression of ureter or bladder, dyspareunia).
- For UAE: documentation of a thorough pre-procedural evaluation by an obstetrician/gynecologist (as recommended) to confirm appropriateness and to facilitate collaboration with interventional radiology.
- Documented absence of contraindications prior to UAE or other procedures: not post-menopausal with fibroid growth/rapid growth, no evidence of current genito-urinary infection and/or malignancy, documentation that the woman does not wish to become pregnant in the future (UAE contraindication), no history of prior pelvic x-ray treatments, pelvic malignancy, chronic infections or severe endometriosis where listed as contraindications.
Key Coverage Criteria
- HCPCS code C1782 (Morcellator) may be covered when selection criteria for morcellation exceptions are met.
- Treatment of uterine fibroids (uterine leiomyoma; ICD-10: D25.0 - D25.9) when the member has persistence of one or more symptoms directly attributed to uterine fibroids, including: excessive menstrual bleeding (menorrhagia), bulk-related pelvic pain, pressure or discomfort, urinary symptoms referable to compression of the ureter or bladder, and/or dyspareunia.
- Radiofrequency ablation (open, laparoscopic e.g., the Acessa System, or transcervical e.g., the Sonata System) medically necessary as an alternative to hysterectomy or myomectomy for treatment of symptomatic uterine fibroids when the above symptom criteria are met.
- Transcatheter uterine artery embolization (UAE; e.g., using tris-acryl gelatin microspheres / Embosphere Microspheres) medically necessary as an alternative to hysterectomy or myomectomy for treatment of symptomatic uterine fibroids when the above symptom criteria are met.
- An option for patients desiring uterine preservation (ACOG notes RFA can be considered in patients who desire uterine preservation, with counseling about limited reproductive data).
- Selected use of power morcellation for removal of uterine fibroids is considered medically necessary (exception to general morcellation restriction) in women without known or strongly suspected uterine cancer in the following situations: 1) premenopausal women who wish to maintain fertility and who have no risk factors for uterine sarcoma (e.g., history of ≥2 years tamoxifen therapy, history of pelvic irradiation, history of childhood retinoblastoma, Lynch syndrome, or hereditary leiomyomatosis [...]
2 Active Policies
HUMANA-UTERINE-FIBROID-SURGICAL-TREATMENTS-MA — Uterine Fibroid Surgical Treatments - Medicare Advantage
AETNA-CPB-0304 — Fibroid Treatment
Related Codes
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