Laparoscopic or transcervical radiofrequency ablation (RFA) as a treatment of symptomatic uterine fibroids is considered medically necessary in women 18 years and older when ALL of the following conditions are met:
Evidence of uterine fibroids via ultrasound that are less than 10 cm in diameter for laparoscopic RFA with Acessa or 7 cm for transcervical RFA with Sonata; AND
Patient desires a uterine-sparing treatment approach or is ineligible for hysterectomy or other uterine-sparing alternatives to RFA (e.g., laparoscopic myomectomy, uterine artery embolization [UAE]) (see Policy Guidelines); AND
Patient has experienced at least 1 of the following symptoms that are a direct result of the fibroid(s):
Menorrhagia or other abnormal uterine bleeding that interferes with daily activities or causes anemia (see Policy Guidelines);
Pelvic pain or pressure;
Urinary symptoms (e.g., urinary frequency, urgency) related to bulk compression of the bladder;
Gastrointestinal symptoms related to bulk compression of the bowel (e.g., constipation, bloating);
Dyspareunia (painful or difficult sexual relations).
Other laparoscopic, transcervical, or percutaneous techniques for myolysis of uterine fibroids, including use of laser or bipolar needles, cryomyolysis, and magnetic resonance imaging-guided laser ablation, are considered investigational.
