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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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uterine artery embolization for treatment of fibroids. January 30, 2004. Available at:

http://www.acog.org/from_home/publications /press_releases/nr01-30-04-2.cfm. Accessed February 4, 2009.

American College of Obstetricians and Gynecologists (ACOG). Alternatives to hysterectomy in the management of leiomyomas. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2008 Aug. 14 p. (ACOG practice bulletin; no. 96).

Barrington JW, Arunkalaivanan AS, Abdel-Fattah M. Comparison between the levonorgestrel intrauterine system (LNGIUS) and thermal balloon ablation in the treatment of menorrhagia. Eur J Obstet Gynecol Reprod Biol. 2003;108(1):72-74.

Barrington JW, Bowen-Simpkins P. The levonorgestrel intrauterine system in the management of menorrhagia. Br J Obstet Gynaecol. 1997;104(5):614-616.

Broder MS, Goodwin S, Chen G, et al. Comparison of long-term outcomes of myomectomy and uterine artery embolization. Obstet Gynecol. 2002;100(5 pt 1):864-868.

Busfield RA, Farquhar CM, Sowter MC, et al. A randomised trail comparing the levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. BJOG. 2006 Mar;113(3):257-63.

Clark TJ and Gupta JK. Outpatient thermal balloon ablation of the endometrium. Fertil Steril. 2004 Nov;82(5):1395-401.

Dysfunctional Uterine Bleeding and Uterine Fibroids- Commercial Medical Management Guideline Cooley S, Yuddandi V, Walsh T, et al. The medium- and long-term outcome of endometrial ablative techniques. Eur J Obstet Gynecol Reprod Biol. 2005 Aug 1;121(2):233-5.

Cooper J, Gimpelson R, Laberge P, et al. A randomized, multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 2002;9(4):418-428.

Corson SL. A multicenter evaluation of endometrial ablation by Hydro ThermAblator and rollerball for treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 2001;8(3):359-367.

Corson SL, Brill AI, Brooks PG, et al. One-year results of the vesta system for endometrial ablation. J Am Assoc Gynecol Laparosc. 2000;7(4):489-497.

Cowan BD, Sewell PE, Howard JC, et al. Interventional magnetic resonance imaging cryotherapy of uterine fibroid tumors: preliminary observation. Am J Obstet Gynecol. 2002;186(6):1183-1187.

Crosignani PG, Vercellini P, Mosconi P, et al. Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. Obstet Gynecol. 1997;90(2):257-263.

Dohi M, Harada J, Mogami T, et al. MR-guided transvaginal cryotherapy of uterine fibroids with a horizontal open MRI system: initial experience. Radiat Med. 2004 Nov-Dec;22(6):391-7.

Duleba AJ, Heppard MC, Soderstrom RM, Townsend DE. A randomized study comparing endometrial cryoablation and rollerball electroablation for treatment of dysfunctional uterine bleeding. J Am Assoc Gynecol Laparosc. 2003;10(1):17ECRI Institute. Target Database: Cryosurgical endometrial ablation for excessive uterine bleeding. April 2004. Archived.

ECRI Institute. Magnetic resonance imaging-guided focused ultrasound ablation of uterine fibroids. June 2008.

ECRI Institute. Target Database: Uterine Fibroid Embolization for Benign Menorrhagia. Updated May 2004. Archived.

Fedele L, Bianchi S, Raffaelli R, et al. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril. 1997;68(3):426-429.

Gallinat A. NovaSure impedance controlled system for endometrial ablation: three-year follow-up on 107 patients. Am J Obstet Gynecol. 2004 Nov;191(5):1585-9.

Glasser MH, Zimmerman JD. The HydroTermAblator System for management of menorrhagia in women with submucous myomas: 12- to 20-month follow-up. J Am Assoc Gynecol Laparosc. 2003 Nov;10(4):521-7.

Goodwin SC, Bradley LD, Lipman JD, et al. Uterine artery embolization versus myomectomy: a multicenter comparative study. Fertil Steril. 2006 Jan;85(1):14-21.

Goodwin SC, Spies JB, Worthington-Kirsch R, Peterson E, Pron G, Li S, Myers ER; Fibroid Registry for Outcomes Data (FIBROID) Registry Steering Committee and Core Site Investigators. Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. Obstet Gyne col. 2008 Jan;111(1):22-33.

Grainger DA, Tjaden BL, Rowland C, Meyer WR. Thermal balloon and rollerball ablation to treat menorrhagia: two-year Dysfunctional Uterine Bleeding and Uterine Fibroids- Commercial Medical Management Guideline results of a multicenter, prospective, randomized, clinical trial. J Am Assoc Gynecol Laparosc. 2000;7(2):175-179.

Hawe J, Abbott J, Hunter D, et al. A randomized controlled trial comparing the Cavaterm endometrial ablation system with the Nd:YAG laser for the treatment of dysfunctional uterine bleeding. BJOG. 2003;110(4):350-357.

Hayes, Inc. Directory. Endometrial Cryosurgery. May 2004. Last update search January 2008. Archived.

Hayes, Inc. Directory. Levonorgestrel-Releasing Intrauterine Device for Dysfunctional Uterine Bleeding. December 2006.

Updated December 2008.

Hayes, Inc. Technology Assessment. Magnetic Resonance Imaging-Guided Cryoablation of Uterine Fibroids. January

2003. Archived Hayes, Inc. Directory. Radiofrequency Endometrial Ablation for Menorrhagia Secondary to Dysfunctional Uterine Bleeding. May 2004. Updated July 2008.





Hayes, Inc. Directory. Thermal Balloon and Hydrothermal Endometrial Ablation. May 2003. Last update search March

2008. Archived.

Hayes, Inc. Directory. Uterine Artery Embolization for Treatment of Fibroids. May 2005. Updated July 2008.

Hayes, Inc. Health Technology Brief. ExAblate 2000 System (InSightec Ltd.) for Ablation of Uterine Fibroids. November

2007. Update search November 2008.

Hindley J, Gedroyc WM, Regan L, et al. MRI guidance of focused ultrasound therapy of uterine fibroids:early results.

AJR Am J Roentgenol 2004 Dec;183(6):1713-9.

Hurskainen R, Teperi J, Rissanen P, et al. Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial. Lancet. 2001;357(9252):273-277.

Istre O, Trolle B. Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection.

Fertil Steril. 2001;76(2):304-309.

Joffre F, Tubiana JM, Pelage JP; Groupe FEMIC. FEMIC (Fibromes Embolisaux MICrosphcalibruterine fibroid embolization using tris-acryl microspheres. A French multicenter study. Cardiovasc Intervent Radiol. 2004;27(6):600-606.

Johnson N, Busfield R, Sadler L, et al. The management of menorrhagia SMART study (Satisfaction with Mirena and Ablation: a Randomised Trial). BJOG. 2001;108(7):773-774.

Kumar S, Suneetha PV, Dadhwal V, Mittal S. Endometrial cryoablation in thetreatment of dysfunctional uterine bleeding.

Int J Gynaecol Obstet. 2002;76(2):189-190.

Laberge PY, Sabbah R, Fortin C, Gallinat A. Assessment and comparison of intraoperative and postoperative pain associated with NovaSure and ThermaChoice endometrial ablation systems. J Am Assoc Gynecol Laparosc.

2003;10(2):223-232.

Lahteenmaki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of levonorgestrel releasing intrauterine system as alternative to hysterectomy. BMJ. 1998;316(7138):1122-1126.

Dysfunctional Uterine Bleeding and Uterine Fibroids- Commercial Medical Management Guideline Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding.

Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002126.

Loffer FD. Three-year comparison of thermal balloon and rollerball ablation in treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 2001;8(1):48-54.

Mara M, Fucikova Z, Maskova J, et al. Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial. Eur J Obstet Gynocol Reprod Biol. 2006;126(2):226-33.

Meyer WR, Walsh BW, Grainger DA, et al. Thermal balloon and rollerball ablation to treat menorrhagia: a multicenter comparison. Obstet Gynecol. 1998;92(1):98-103.

Milliman Care Guidelines. Ambulatory Care. 13th Edition. Fibroid Tumors and Abnormal Uterine Bleeding.

National Institute for Health and Clinical Excellence (NICE); September 2007 (Interventional procedure guidance; no.

231).Magnetic resonance image-guided transcutaneous focused ultrasound ablation for uterine fibroids. Available at:

http://www.nice.org.uk/nicemedia/pdf/IPG231Guidance.pdf. Accessed April 2009.

Pinto I, Chimeno P, Romo A, et al. Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment. A prospective, randomized, and controlled clinical trial. Radiology. 2003;226(2):425-431.

Pittrof R, Majid S, Murray A. Transcervical endometrial cryoablation (ECA) for menorrhagia. Int J Gynaecol Obstet.

1994;47(2):135-140.

Pron G, Cohen M, Soucie J, et al. The Ontario uterine fibroid embolization trial. Fertil Steril. 2003b;79(1):120-127.

Razavi MK, Hwang G, Jahed A, et al. Abdominal myomectomy versus uterine fibroid embolization in the treatment of symptomatic uterine leiomyomas. AJR Am J Roentgenol. 2003;180(6):1571-1575.

Romer T. Prospective comparison study of levonorgestrel IUD versus Roller-Ball endometrial ablation in the management of refractory recurrent hypermenorrhea. Eur J Obstet Gynecol Reprod Biol. 2000;90(1):27-29.

Rosenbaum SP, Fried M, Munro MG. Endometrial hydrothermablation: A comparison of short-term clinical effectiveness in patients with normal endometrial cavities and those with intracavitary pathology. J Minim Invasive Gynecol. 2005 MarApr;12(2):144-9.

Rutherford TJ, Zreik TG, Troiano RN, et al. Endometrial cryoablation, a minimally invasive procedure for abnormal uterine bleeding. J Am Assoc Gynecol Laparosc. 1998;5(1):23-28.

Sewell PE, Arriola RM, Robinette L, Cowan BD. Real-time I-MR-imaging-guided cryoablation of uterine fibroids. J Vasc Interv Radiol. 2001;12(7):891-893.

Shaamash AH, Sayed EH. Prediction of successful menorrhagia treatment after thermal balloon endometrial ablation. J Obstet Gynaecol Res. 2004 Jun;30(3):210-6.

Siskin GP, Shlansky-Goldberg RD, Goodwin SC, et al. A prospective multicenter comparative study between myomectomy and uterine artery embolization with polyvinyl alcohol microspheres: long-term clinical outcomes in patients with symptomatic uterine fibroids. J Vasc Interv Radiol. 2006;17(8):1287-95.

Dysfunctional Uterine Bleeding and Uterine Fibroids- Commercial Medical Management Guideline Soysal ME, Soysal SK, Vicdan K. Thermal balloon ablation in myoma-induced menorrhagia under local anesthesia.

Gynecol Obstet Invest. 2001;51(2):128-133.

Spies JB, Allison S, Flick P, et al. Polyvinyl alcohol particles and tris-acryl gelatin microspheres for uterine artery embolization for leiomyomas: results of a randomized comparative study. J Vasc Interv Radiol. 2004;15(8):793-800.

Spies JB, Bruno J, Czeyda-Pommersheim F, et al. Long-term outcome of uterine artery embolization of leiomyomata.

Obstet Gynecol. 2005 Nov;106(5Pt1):933-9.

Stewart EA, Rabinovici J, Tempany C, et al. Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids. Fertil Steril. 2006 Jan;85(1):22-9.

Townsend DE, Duleba AJ, Wilkes MM. The Endometrial Cryoablation Study Group. Durability of treatment effects after endometrial cryoablation versus rollerball electroablation for abnormal uterine bleeding: two-year results of a multicenter randomized trial. Am J Obstet Gynecol. 2003;188(3):699-701.

.

Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up. Br J Obstet Gynaecol. 2002;109(11):1262-1272.

Zupi E, Marconi D, Sbracia M, et al. Directed laparoscopic cryomyolysis for symptomatic leiomyomata: one-year follow up. J Minim Invasive Gynecol. 2005 Jul-Aug;12(4):343-6.

History/Updates Policy revision with changes to the coverage rationale. Policy 2009T0442D archived.

8/21/2009 Policy revision with changes to the coverage rationale. CMS information updated. Deleted CPT code 6/5/2009 37204 from the coding section. Policy 2008T0442C archived.

Policy update. CMS information and coding updated. Policy 2007T0442B archived.

12/1/2008 CPT code 37210 added per Manager, Coding and Integrity.

6/18/2008 Links to CMS sites corrected with no change in language in any section 3/14/2008 Policy updated. Policy 2006T0442B archived 10/18/2007 CPT code 0009T removed from Coding Section and CPT codes 0071T, 0072T, 37204 and 75894 and 12/12/2006 HCPCS codes J7302 and J7306 added per direction from the Reimbursement Medical Policy Operations Manager.

Update that adds an indication and combines the following policies: Uterine Cryosurgery 2003T0442A, 10/19/2006 Thermal Balloon and Hydrothermal Endometrial Ablation 2003T0037D, Levonorgestrel-Releasing Intrauterine Device for Treatment of Dysfuntional Uterine Bleeding 2002T0399A, Radiofrequency Endometrial Ablation for Menorrhagia Secondary to Dysfunctional Uterine Bleeding 2004T0460A, Uterine Artery Embolization for Uterine Fibroids 2005T0066C, Magnetic Resonance Imaging-Guided Cryoablation of Uterine Fibroids 2003T0420A CPT codes 58353, 58356, 58563 added to Coding Section per direction from the Reimbursement 1/5/2005 Medical Policy Operations Manager.

Dysfunctional Uterine Bleeding and Uterine Fibroids- Commercial Medical Management Guideline Medicare language added; Medicare Benefit Policy Manual, Ch. 16, Sec. 20.

4/2/2004 Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.com with the word "Medical" in the subject line.

Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.

Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.



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