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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2003 Title: Uterine Artery Embolization
Revision Date: 10/10/2008 Document: BI234:00
CPT Code(s): 37210
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Uterine artery embolization is a non-surgical outpatient procedure used to treat focal or localized problems in the uterus. The most common problem of this nature is fibroids. Fibroids may cause problems because of their size or because they can cause excessive menstrual bleeding.

2)    Uterine artery embolization is covered by QualChoice as an alternative to hysterectomy for women with fibroids.

3)    In Uterine artery embolization, a catheter is threaded through the artery (usually starting at the groin) to the uterus. X-ray pictures are taken using dye to be sure the catheter is in the right place to stop blood supply to the fibroid. Then the artery to the fibroid is filled with small glass beads that cause the blood to clot and result in there being no blood flow to the fibroid. The fibroid then dies and shrinks away.


Medical Statement

1)    Uterine Artery Embolization (UAE) is an outpatient procedure using angiographic techniques and fluoroscopic guidance to occlude the blood supply to uterine fibroids.  This results in an ischemic infarction of the fibroids and a decrease in their size and bulk over a period of weeks and months.  QualChoice covers UAE as an alternative to hysterectomy or myomectomy for the treatment of uterine fibroids.

2)    Uterine Artery Embolization (UAE) is covered when ALL the following are met:

a)    The patient has persistence of one or more symptoms directly attributed to uterine fibroids:

i)      Excessive menstrual bleeding

ii)     Bulk-related pain, pressure or discomfort

iii)    Urinary symptoms due to compression of the ureter or bladder and/or dyspareunia

b)    The physician and patient determine that available surgical alternatives (hysterectomy and myomectomy) are not appropriate.

3)    Peer reviewed medical literature does not support the performance of uterine artery embolization in patients with the following conditions and is not covered:

a)    Patient has a history of prior pelvic x-ray treatments, pelvic malignancy, chronic infections or severe endometriosis; or

b)    Postmenopausal women with fibroid growth or rapid growth at any time (may indicate development of sarcoma).

 

Codes Used In This BI:

37210 – Embolization Uterine Fibroid


Reference

1)      Reidy JF, Bradley EA. Uterine artery embolization for fibroid disease. Cardiovasc Intervent Radiol. 1998;21(5):357-360.

2)      Mason BA. Postpartum hemorrhage and arterial embolization. Curr Opin Obstet Gynecol. 1998;10(6):475-479.

3)      Vedantham S, Goodwin SC, McLucas B, et al. Uterine artery embolization: An underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol. 1997;176(4):938-948. 

4)      Aziz A, et al. Transarterial embolization of the uterine arteries: Patient reactions and effects on uterine vasculature. Acta Obstet Gynecol Scand. 1998;77(3):334-340.

5)      Goodwin SC, Walker WJ. Uterine artery embolization for the treatment of uterine fibroids. Curr Opin Obstet Gynecol. 1998;10(4):315-320. 

6)      Goodwin SC, et al. Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol. 1997;8(4):517-526. 

7)      Bradley EA, et al. Transcatheter uterine artery embolisation to treat large uterine fibroids. Br J Obstet Gynaecol. 1998;105(2): 235-240. 

8)      Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet. 1995;346(8976):671-672.

9)      Worthington-Kirsch RL, Popky GL, Hutchins FL. Uterine arterial embolization for the management of leiomyomas: Quality-of-life assessment and clinical response. Radiology. 1998;208:625-629. 

10)  Andersen PE, Lund N, Justesen P, et al. Uterine artery embolization of symptomatic uterine fibroida . Initial success and short-term results. Acta Radiol. 2001;42(2):234-238. 

11)  Smith SJ. Uterine fibroid embolization. Am Fam Physician. 2000;61(12):3601-3607, 3611-3612. 

12)  Wong GC, Muir SJ, Lai AP, et al. Uterine artery embolization: A minimally invasive technique for the treatment of uterine fibroids. J Womens Health Gend Based Med. 2000;9(4):357-362.

13)  Todd A. An alternative to hysterectomy. RN. 2002;65(3):30-35.

14)  Watson GM, Walker WJ. Uterine artery embolisation for the treatment of symptomatic fibroids in 114 women: reduction in size of the fibroids and women`s views of the success of the treatment. BJOG. 2002;109(2):129-135.

15)  Lumsden MA. Embolization versus myomectomy versus hysterectomy: which is best, when? Hum Reprod. 2002;17(2):253-259.

16)  Nevadunsky NS, Bachmann GA, Nosher J, et al. Women`s decision-making determinants in choosing uterine artery embolization for symptomatic fibroids. J Reprod Med. 2001;46(10):870-874.

17)  Uterine artery embolization for leiomyomata. Clin Privil White Pap. 2001;(63):1-7.

18)  Badawy SZ, Etman A, Singh M, et al. Uterine artery embolization: the role in obstetrics and gynecology. Clin Imaging. 2001;25(4):288-295.

19)  Floridon C, Lund N, Thomsen SG. Alternative treatment for symptomatic fibroids. Curr Opin Obstet Gynecol. 2001;13(5):491-495.

20)  Machan L, Martin M. Uterine artery embolization to treat uterine fibroids. Can Assoc Radiol J. 2001;52(3):183-187.

21)  Spies JB, Ascher SA, Roth AR, et al. Uterine artery embolization for leiomyomata. Obstet Gynecol. 2001;98(1):29-34.

22)  Klein A, Schwartz ML. Uterine artery embolization for the treatment of uterine fibroids: an outpatient procedure. Am J Obstet Gynecol. 2001;184(7):1556-1563.

23)  Goodwin SC, Wong GC. Uterine artery embolization for uterine fibroids: a radiologist`s perspective. Clin Obstet Gynecol. 2001;44(2):412-424.


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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