Medical Policy



Subject: Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
Document #: SURG.00077 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses laparoscopic and percutaneous ablative techniques for the treatment of symptomatic uterine fibroids. Uterine fibroids, also referred to as leiomyomas, are a common condition affecting women in their reproductive years; symptoms include excessive menstrual bleeding and pelvic pain.

 Note: Please see the following related document(s) for additional information:

Position Statement

Investigational and Not Medically Necessary:

The use of laparoscopic or percutaneous ablation techniques in combination with imaging guidance as a treatment of uterine fibroids is considered investigational and not medically necessary, including but not limited to lasers, bipolar electrodes, interstitial thermotherapy, cryotherapy, and radiofrequency ablation.

Rationale

With one exception, the published literature regarding the techniques for myolysis is limited and of poor quality, even though some techniques, such as Nd:YAG laser myolysis have been available since the early 1990s. There are no controlled clinical trials comparing myolysis with hysterectomy, and one randomized controlled trial (RCT) comparing myolysis with myomectomy, which only reported interim results. The available studies largely lack pertinent information such as uterine size, number and size of fibroids, location of fibroids (i.e., either subserosal, intramural or submucosal), and recurrence rates. Clinical outcomes have been inconsistent or not reported. Evidence regarding the varied myolysis techniques is summarized below.

Cryomyolysis is a technique in which a cryoprobe is inserted into the center of a fibroid. Freezing temperatures of minus 180 degrees centigrade create an "iceball" within the fibroid. Several freeze/thaw cycles are typically used. Zreik and colleagues presented their preliminary experience with 14 women, while Zupi and colleagues (2004) presented their initial experience with 20 women. In both of these small case series, the authors reported symptom resolution. In the Zreik (1998) study, the participants were given GnRH agonist before the procedure; cryomyolysis maintained or slightly reduced the post-GnRH uterine size. In contrast, GnRH was not used in the Zupi study, and cryomyolysis was associated with a 25% reduction in fibroid size.

Garza and colleagues (2011) reported a feasibility study using laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation (RFVTA) in 31 women with symptomatic uterine leiomyomas. The primary outcome measures were safety, frequency of adverse events, repeat intervention rate because of symptoms of myoma, symptom severity, and health-related quality-of-life scores from the validated Uterine Fibroid Symptom and Quality-of-Life Questionnaire. Secondary outcome measures were uterine volume changes over time. At 3, 6, and 12 months, mean symptom severity scores improved significantly compared with baseline, by 59.7% (95% confidence interval [CI], 44.8-74.7); 71.7% (95% CI, 55.7%-87.7%); and 82.0% (95% CI, 70.9%-93.1%), respectively. The increase in mean health-related quality-of-life scores over time reached statistical significance (p<0.001): 60.15 (95% CI, 51.6%-68.7%) at baseline, 87.9 (95% CI, 82.1%-93.7%) at 3 months, 90.8 (95% CI, 82.1%-99.5%) at 6 months, and 97.8 (95% CI, 96.2-99.4) at 12 months. Average uterine volume decreased from a mean baseline value of 194.4 (± 105.9 cm3 ) to 159.5 (± 66.8 cm3 ) at 3 months, to 147.2 (± 73.0 cm3 ) at 6 months, and to 113.2 (± 53.5 cm3 ) at 12 months (p=0.006). The authors found that thermal ablation produced significant reduction in symptoms and improvement in quality of life at 1 year post-treatment. They concluded that additional larger, multi-center studies are needed to confirm these results.

A similar prospective case series study of laparoscopic ultrasound-guided RFVTA was reported by Robles (2013). This study involved 35 subjects with symptomatic uterine fibroids. The authors reported that there was a significant improvement in average symptom reduction (p<0.001), symptom severity (p<0.05), health-related quality of life (HR-QOL) measures at 12 months (p<0.001), and decrease in the duration of menses (p=0.033). At 12 months, 70.6% (24/34) reported being symptom free, compared with 0% at baseline. Change in uterine volume did not reach statistical significance at any time point. Study authors reported nine adverse events, but none were considered related to the device or procedure.

Phase II and III results of a retrospective study evaluating RFVTA in 206 participants was reported by Galen and colleagues (2014). In the phase II study, from baseline to 12 months, participants experienced significant reductions in symptom severity (p<0.001); HR-QOL scores (p<0.001); and mean uterine volume (p=0.008). The rate of adverse events associated with the RFVTA procedure was relatively low at 1.4% (1 of 69). Similar significant results were reported in the phase III study when assessed at 12 months, although the rate of adverse events related to the procedure was 3.5% (5 of 137). This study was limited by the retrospective study design and relatively small sample size.

Chudnoff and colleagues (2013) reported on the results of a case series involving 135 subjects with symptomatic uterine myomas who underwent laparoscopic ultrasound-guided RFVTA. Subjects were premenopausal women with uterine size of 14 weeks gestation or less and six or fewer treatable myomas. No myoma was larger than 7 cm in diameter and total myoma volume was 300 cm3 or less. At 12 months, 127 subjects were included in the analysis. A total of 8 subjects were excluded due to inability to provide catamenial products (n=4), pregnancy (n=3), and Hashimoto's disease (n=1). The authors reported that monthly menstrual blood loss was significantly improved with a percent change in alkaline hematin from baseline of -32% (p<0.001) at 3 months, -41% (p<0.001) at 6 months, and -38% (p<0.001) at 12 months. Total mean uterine volume decreased 15.7% at 3 months and 24.3% at 12 months (p<0.001 at both time points). Similarly, the mean myoma volume decreased by 39.8% at 3 months and by 45.1% at 12 months (p<0.001 at both time points). Results on the Uterine Fibroid Symptom and Quality of Life Questionnaire indicated significant improvements in both symptom severity and HR-QOL (p<0.001 for both measures). Similar results were also reported for the responses on the EQ-5DTM Health Status score (p<0.001). Further study using randomized controlled trials are needed to confirm the results of this case series.

Guido and colleagues (2013) conducted a prospective uncontrolled study to evaluate RFVTA of symptomatic uterine fibroids in 121 premenopausal women (HALT Trial). At the 24-month follow-up, subjects showed a significant improvement in symptom severity compared with baseline values (p<0.001), as well as significant improvements in HR-QOL scores in all categories (p<0.001). A total of 6 individuals (4.8%) required repeat surgical intervention for bleeding related to fibroids between 12 and 24 months. At 36 months of follow-up, Berman (2014) reported similar results in 104 subjects from the same trial. RFVTA resulted in continued and significant relief from symptoms of uterine fibroids, including significant improvements in HR-QOL scores. At 36 months, the total rate of re-intervention was 11% (14 of 135 subjects). Despite positive outcomes, these studies lacked randomization and a control group.

Brucker and colleagues (2014) conducted a blinded RCT to compare RFVTA and laparoscopic myomectomy in 51 women with symptomatic fibroids. Study authors reported interim study results of hospitalization time and perioperative outcomes. Participants in the treatment group experienced significantly faster discharge from the hospital (8.2 ± 5.3 hours) compared with participants in the myomectomy group (28 ± 13.8 hours; p<0.001). The mean hospital time for the treatment group was 10.0 ± 5.5 hours compared with the 29.9 ± 14.2 hours for the comparator group (p<0.001). The mean operative blood loss for the treatment group was 16 ± 9 mL compared with 51 ± 57 mL for the comparator group (p<0.001). In 2016, another interim analysis of this study was published at 24-month follow-up (Kramer, 2016). Improvements in the severity of symptoms from baseline were reported by participants in both the RFVTA (p=0.001) and laparoscopic myomectomy arms (p=0.001). A significant improvement in HR-QOL scores was reported in the laparoscopic myomectomy group (p=0.040); however, a non-significant improvement was recorded in the RFVTA group (p=0.083). Study limitations include manufacturer sponsorship of the trial, homogenous sample population (lack of ethnic diversity), and interim reporting of study results. Study participants will continue to be followed for the remainder of this 5-year study.

In 2017, Liu and colleagues published results of a prospective, cohort trial in which 311 Chinese women were enrolled across 8 centers and underwent ultrasound-guided percutaneous microwave ablation therapy for symptomatic uterine fibroids. Women were evaluated at baseline, 3, 6 and 12 months for fibroid size, hemoglobin level, uterine fibroid symptoms and HR-QOL scores. The mean reduction rate in fibroid volume was 63.5%, 78.5% and 86.7% at 3, 6 and 12 months, respectively (p<0.001). The mean hemoglobin level increased significantly from 88.84 ± 9.31 g/L at baseline to 107.14 ± 13.32, 116.05 ± 7.66 and 117.79 ± 6.51 g/L at 3, 6 and 12 months posttreatment, respectively (p<0.000). The symptom severity score (SSS) and HR-QOL scores were also significantly improved at each follow-up compared with baseline (p<0.000). While these results are promising, a randomized trial comparing microwave ablation of uterine fibroids to standard of care, in a diverse population with long-term outcomes, is warranted. 
The availability of open MRI scanners with both vertical and horizontal access capabilities has created interest in using MRI image guidance for percutaneous myolysis procedures. For example, percutaneous placement of probes into the fibroids can be guided with real time imaging that can provide thermal imaging maps of the treated area useful for monitoring thermal changes in the tissue. Previously, in laparoscopic procedures thermal damage was assessed only visually by observing a blanching of the serosa, which may be too late to avoid serosal damage. It is thought that MRI monitoring of thermal damage within the fibroid may reduce the risk of serosal damage and subsequent adhesions. Hindley (2002) and colleagues reported on a case series of 66 women with symptomatic fibroids who were treated with MRI-guided percutaneous Nd:YAG laser myolysis. Outcome measures included assessment of fibroid size and a menorrhagia questionnaire. The mean reduction in size of fibroids was 31%. Compared to a control group of those undergoing hysterectomy, the total outcome score was less in those undergoing percutaneous myolysis but the quality of life score was similar. Although not entirely clear, it appears that treatment was targeted to only the largest fibroid in each woman. The study does not provide details on the number and location of fibroids. It should also be noted that MRI guidance was provided with a high field (0.5T) open machine.

A health technology assessment by Viswanathan (2007) concluded that there is a paucity of high-quality evidence supporting the effectiveness of most interventions for uterine fibroids. The current published medical literature does not permit definitive conclusions about the benefit, harm or relative costs to help guide women's choices. Significant research gaps include well-conducted trials in U.S. populations that directly compare interventions using short and long-term health outcomes.

The American College of Obstetricians and Gynecologists (ACOG) (2008) guideline entitled, Alternatives to Hysterectomy in the Management of Leiomyomas, states that they do not recommend percutaneous techniques for myolysis as a treatment of uterine fibroids.

In 2008, the American Society of Reproductive Medicine (ASRM) in collaboration with the Society of Reproductive Surgeons (SRS) published a joint statement regarding myomas and reproductive function. In this document they state:

Another laparoscopic technique, myolysis, involves thermal destruction of myomas via insertion of cryoprobes, electrocautery needles, or fiberoptic lasers.  A nonsurgical method for myolysis involving MRI-guided focused ultrasound has also been described.  Data relating to the short- and long-term outcomes achieved with such treatments are still lacking and, until they become available, myolysis cannot be recommended for women hoping to maintain or improve their fertility.

A 2011 consensus statement on fibroids in infertility by the Australasian Certification in Reproductive Endocrinology and Infertility (CREI) Consensus Expert Panel on Trial (ACCEPT) evidence, states the following:

Fibroid myolysis: Myolysis involves the placement of probes within the fibroid, usually by laparoscopy, followed by the use of bipolar or monopolar heat, cold (cryomyolysis) or laser to destroy the tissue. While potentially effective at reducing fibroid volume, pregnancy outcomes are unclear.

And;

Radiofrequency thermal ablation: This procedure uses an ultrasound- or laparoscopy-guided needle electrode to heat fibroid tissue and cause tissue necrosis. Early reports of outcomes in terms of reduced fibroid volume are encouraging, but reproductive parameters are unknown.

In 2015 an evidence-based guideline was published by the Journal of Obstetrics and Gynaecology Canada (JOGC) with the following recommendation, "Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients...Newer focused energy delivery methods are promising but lack long-term data."

There is inadequate and poor quality evidence to permit scientific conclusions regarding various laparoscopic or MRI-guided myolysis techniques. The published studies are inconsistent in the reporting of outcomes, such as fibroid size, location and associated symptoms. The gold standard technique is hysterectomy, although myomectomy may be considered the gold standard for a uterine sparing procedure. Hysterectomy sparing procedures are generally performed in effort to preserve fertility. However, the published clinical studies evaluating myolysis techniques primarily include only those women who have completed childbearing. MRI-guided percutaneous therapies and image-guided laparoscopic radiofrequency ablation techniques for fibroids are currently being evaluated in ongoing clinical trials.

Background/Overview

Uterine fibroids are one of the most common conditions affecting women during their reproductive years. Symptoms include menorrhagia, pelvic pressure, or pain. Hysterectomy and various myomectomy procedures are considered the gold standard of treatment. However, there has been continual research interest in developing minimally invasive alternatives that may preserve fertility, including endometrial ablation (for submucosal fibroids), uterine artery embolization, and various techniques to induce myolysis. Several types of energy sources have been used for myolysis, including Nd:YAG lasers, bipolar electrodes, cryotherapy, or radiofrequency ablation. In general, the procedures involve the insertion of probes multiple times into the fibroid. When activated, the various energy sources induce devascularization and ultimately ablation of the target tissue. When radiofrequency ablation is used, the procedure may be referred as the HALT (Hysterectomy Alternative) procedure.

Myolysis, a surgical procedure that involves the destruction of uterine fibroids (also referred to as leiomyomas), has typically been performed during a laparoscopic procedure focusing on subserosal and intramural fibroids; more recently, percutaneous approaches with MRI guidance have been reported. Typically, women are pretreated with depot gonadotropin-releasing hormone (GnRH) agonists, over a period of 2 to 6 months, to shrink fibroids prior to the procedure.

Definitions

Fibroids: Fibrous tissue collected in the uterine wall; also referred to as leiomyomas.

Laparoscopic: A surgical procedure performed using a laparoscope, a thin fiberoptic scope introduced into a body cavity for diagnostic and surgical purposes.

Magnetic resonance imaging (MRI): The use of a nuclear magnetic resonance spectrometer to produce electronic images of specific atoms and molecular structures in solids, especially human cells, tissues and organs.

Myolysis: The dissolution of muscular tissue.

Percutaneous: A medical procedure in which access to inner organs or other tissue is achieved via puncture of the skin.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:

CPT  
58578 Unlisted laparoscopy procedure, uterus [when specified as laparoscopic ablation by laser, bipolar electrodes, interstitial thermotherapy, cryotherapy]
58674 Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency
58999 Unlisted procedure, female genital system (nonobstetrical) [when specified as image-guided percutaneous ablation by laser, bipolar electrodes, interstitial thermotherapy, cryotherapy, radiofrequency]
   
ICD-10 Procedure  
0U593ZZ Destruction of uterus, percutaneous approach
0U594ZZ Destruction of uterus, percutaneous endoscopic approach
   
ICD-10 Diagnosis  
D25.0-D25.9 Leiomyoma of uterus
   
References

Peer Reviewed Publications:

  1. Bergamini V, Ghezzi F, Cromi A, et al. Laparoscopic radiofrequency thermal ablation: a new approach to symptomatic uterine myomas. Am J Obstet Gynecol. 2005; 192(3):768-773.
  2. Berman JM, Guido RS, Garza Leal JG, et al. Three-year outcome of the Halt trial: a prospective analysis of radiofrequency volumetric thermal ablation of myomas. J Minim Invasive Gynecol. 2014; 21(5):767-774.
  3. Brucker SY, Hahn M, Kraemer D, et al. Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy. Int J Gynaecol Obstet. 2014; 125(3):261-265.
  4. Chudnoff SG, Berman JM, Levine DJ, et al. Outpatient procedure for the treatment and relief of symptomatic uterine myomas.  Obstet Gynecol. 2013; 121(5):1075-1082.
  5. Donnez J, Squifflet J, Polet R, Nisolle M. Laparoscopic myolysis. Hum Reprod Update. 2000; 6(6):609-613.
  6. Galen DI, Isaacson KB, Lee BB et al. Does menstrual bleeding decrease after ablation of intramural myomas? A retrospective study. Journal of Min Invasive Gynecology. 2013. 20(6):830-835.
  7. Galen DI, Pemeuller RR, Leal JG, et al. Laparoscopic radiofrequency fibroid ablation: phase II and phase III results. JSLS. 2014; 18(2):182-190.
  8. Garza Leal JG, Hernandez LI, Castillo SL, Lee BB. Laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation of symptomatic uterine leiomyomas: feasibility study using the Halt 2000 Ablation System. J Minim Invasive Gynecol. 2011; 18(3):364-371.
  9. Goldfarb H. Bipolar laparoscopic needles for myoma coagulation. J Am Assoc Gynecol Laparosc. 1995; 2(2):175-179.
  10. Goldfarb HA. Nd:YAG laser laparoscopic coagulation of symptomatic myomas. J Reproductive Med. 1992; 37(7):636-638.
  11. Guido RS, Macer JA, Abbott K, et al. Radiofrequency volumetric thermal ablation of fibroids: a prospective, clinical analysis of two years' outcome from the Halt trial. Health Qual Outcomes. 2013; 11(1):139.
  12. Hindley JT, Law PA, Hickey M, et al. Clinical outcomes following perctuaneous magnetic resonance image guided laser ablation of symptomatic uterine fibroids. Hum Reprod. 2002; (1)7:2737-2741.
  13. Iversen H, Lenz S, Dueholm M. Ultrasound-guided radiofrequency ablation of symptomatic uterine fibroids: short-term evaluation of effect of treatment on quality of life and symptom severity. Ultrasound Obstet Gynecol. 2012; 40(4):445-451.
  14. Kolankaya A, Arici A. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am. 2006; 33(1):145-152.
  15. Krämer B, Hahn M, Taran FA, et al. Interim analysis of a randomized controlled trial comparing laparoscopic radiofrequency volumetric thermal ablation of uterine fibroids with laparoscopic myomectomy. Int J Gynaecol Obstet. 2016; 133(2):206-211.
  16. Law P, Gedroyc WM, Regan L. Magnetic resonance-guided percutaneous laser ablation of uterine fibroids. J Magn Reson Imaging. 2000; 12(4):565-570.
  17. Liu H, Zhang J, Han ZY, et al. Effectiveness of ultrasound-guided percutaneous microwave ablation for symptomatic uterine fibroids: a multicentre study in China. Int J Hyperthermia. 2016; 32(8):876-880.
  18. Milic A, Asch MR, Hawrylyshyn PA, et al.  Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroids. Cardiovasc Intervent Radiol. 2006; 29(4):694-698.
  19. Phillips DR, Nathanson HG, Milim SH, et al. Laparoscopic leiomyoma coagulation. J Am Assoc Gynecol Laparosc. 1996; 3(4 Suppl):S39.
  20. Robles R, Aguirre VA, Argueta AI, Guerrero MR. Laparoscopic radiofrequency volumetric thermal ablation of uterine myomas with 12 months of follow-up. Int J Gynaecol Obstet. 2013; 120(1):65-69.
  21. Sakuhara Y, Shimizu T, Kodama Y, et al. Magnetic resonance-guided percutaneous cryoablation of uterine fibroids: early clinical experiences. Cardiovasc Intervent Radiol. 2006; 29(4):552-558.
  22. Shen SH, Fennessy F, McDannold N, et al. Image-guided thermal therapy of uterine fibroids. Semin Ultrasound CT MR. 2009; 30(2):91-104.
  23. Vilos GA, Allaire C, Laberge PY, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015; 37(2):157-181.
  24. Visvanathan D, Connell R, Hall-Craggs MA, et al. Interstitial laser photocoagulation of uterine myomas. Am J Obstet Gynecol 2002; 18(7):382-384.
  25. Yang Y, Zhang J, Han ZY et al. Ultrasound-guided percutaneous microwave ablation for submucosal uterine fibroids. J Minim Invasive Gynecol. 2014; 21(3):436-441.
  26. Zreik TG, Rutherford TJ, Palter SF, et al. Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids. J Am Assoc Gynecol Laparosc. 1998; 5(1):33-38.
  27. Zupi E, Piredda A, Marconi D, et al. Directed laparoscopic cryomyolysis: a possible alternative to myomectomy and/or hysterectomy for symptomatic leiomyomas. Am J Obstet Gynecol. 2004; 190(3):639-643.
  28. Zupi E, Marconi D, Sbracia M, et al. Directed laparoscopic cryomyolysis for symptomatic leiomyomata: one-year follow up. J Minim Invasive Gynecol. 2005; 12(4):343-346.
  29. Zupi E, Sbracia M, Marconi D, Munro MG. Myolysis of uterine fibroids: is there a role? Clin Obstet Gynecol. 2006; 49(4):821-833.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Obstetricians and Gynecologists (ACOG) practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008; 112(2 Pt 1):387-400.
  2. American Society of Reproductive Medicine. Myomas and reproductive function. The Practice Committee of the American Society of Reproductive Medicine in collaboration with the Society of Reproductive Surgeons. Fertili Steril. 2008; 910(5 Suppl):S125-S130.
  3. Kroon B, Johnson N, Chapman, et al; Australasian CREI Consensus Expert Panel on Trial evidence (ACCEPT) group. Fibroids in infertility – consensus statement from ACCEPT (Australasian CREI Consensus Expert Panel on Trial evidence). Aust N Z J Obstet Gynaecol. 2011; 51(4):289-295.
  4. Metwally M, Cheong YC, Horne AW. Surgical treatment of fibroids for subfertility. Cochrane Database Syst Rev. 2012;(11):CD003857.
  5. Viswanathan M, Hartmann K, McKoy N, et al. Management of uterine fibroids: an update of the evidence. Agency for Healthcare Research and Quality (AHRQ), Evidence report/technology assessment No. 154. 2007. Available at: http://www.ncbi.nlm.nih.gov/books/NBK38746/. Accessed on June 27, 2017.
Websites for Additional Information
  1. National Institute of Child Health and Human Development. Surgical treatments for fibroids. Available at: http://www.nichd.nih.gov/health/topics/uterine/conditioninfo/treatments/Pages/surgical-treatments.aspx. Accessed on June 27, 2017.
  2. National Library of Medicine. Medline Plus Health Topics: Uterine fibroids. Updated on June 14, 2017. Available at: http://www.nlm.nih.gov/medlineplus/uterinefibroids.html. Accessed on June 27. 2017.
Index

Laparoscopic
Myolysis
Percutaneous
Radiofrequency volumetric thermal ablation (RFVTA)
Uterine Fibroids

Document History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Rationale, Background/Overview and References sections updated.
  01/01/2017 Updated Coding section with 01/01/2017 CPT changes; removed code 0336T deleted 12/31/2016.
Reviewed 08/04/2016 MPTAC review. References section updated. Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review. Rationale and References sections updated.
Reviewed 08/14/2014 MPTAC review. Rationale and Reference sections updated.
  01/01/2014 Updated Coding section with 01/01/2014 CPT and HCPCS changes; removed C9736 deleted 12/31/2013.
Reviewed 08/08/2013 MPTAC review. Clarified title and position statement.  Rationale, References and Index sections updated.
  07/01/2013 Updated Coding section with 07/01/2013 HCPCS changes.
Reviewed 08/09/2012 MPTAC review. Rationale and References updated.
Reviewed 08/18/2011 MPTAC review. Rationale and References updated.
Reviewed 08/19/2010 MPTAC review. References updated.
Reviewed 08/27/2009 MPTAC review. Rationale and references updated.
Reviewed 08/28/2008 MPTAC review. References updated.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 08/23/2007 MPTAC review. References updated.
Reviewed 09/14/2006 MPTAC review. References updated. Removed CMS NCD, added November 2005 in error.
  11/21/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 09/22/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
     
Pre-Merger Organizations Last Review Date Document Number

Title

 

Anthem, Inc.   No prior document  
WellPoint Health Networks, Inc. 6/24/2004 3.09.10 Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids