Aetna · Clinical coverage policy

Aetna Fibroid Treatment coverage criteria

Aetna CPB 0304 covers radiofrequency ablation (open, laparoscopic, or transcervical) and uterine artery embolization (UAE) as medically necessary alternatives to hysterectomy or myomectomy when the patient has at least one symptom directly attributed to uterine fibroids (heavy menstrual bleeding, bulk-related pelvic pain/pressure, urinary compression symptoms, or dyspareunia). Power morcellation is allowed only in narrow situations for women without known/suspected uterine cancer and is otherwise considered experimental, while focused ultrasound (MRgFUS), cryomyolysis, lasers, acupuncture and several other modalities are deemed experimental/investigational.

Policy CPB 0304 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0304

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0304 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Fibroid Treatment (CPT 58580), and what gets it denied?

Path
Aetna CPB 0304 covers radiofrequency ablation (open, laparoscopic, or transcervical) and uterine artery embolization (UAE) as medically necessary alternatives to hysterectomy or myomectomy when the patient has at least one symptom directly attributed to uterine fibroids (heavy menstrual bleeding, bulk-related pelvic pain/pressure, urinary compression symptoms, or dyspareunia). Power morcellation is allowed only in narrow situations for women without known/suspected uterine cancer and is otherwise considered experimental, while focused ultrasound (MRgFUS), cryomyolysis, lasers, acupuncture and several other modalities are deemed experimental/investigational. Coverage criteria include: Radiofrequency ablation (RFA) of uterine fibroids — open, laparoscopic (e.g., the Acessa System), or transcervical (e.g., the Sonata System) — is medically necessary as an alternative to hysterectomy or myomectomy when the member has persistence of ONE OR MORE symptoms directly attributed to uterine fibroids (i.e., ANY of): excessive menstrual bleeding (menorrhagia); bulk-related pelvic pain, pressure or discomfort; urinary symptoms referable to compression of the ureter or bladder; and/or dyspareunia.; Transcatheter uterine artery embolization (UAE) — e.g., by means of polyethylene glycol microspheres (HydroPearl) or tris-acryl gelatin microspheres (Embosphere Microspheres) — is medically necessary as an alternative to hysterectomy or myomectomy for the treatment of uterine fibroids when the member has persistence of ONE OR MORE symptoms directly attributed to uterine fibroids (i.e., ANY of): excessive menstrual bleeding (menorrhagia); bulk-related pelvic pain, pressure or discomfort; urinary symptoms referable to compression of the ureter or bladder; and/or dyspareunia.; Fibroid removal with power morcellation (myomectomy or hysterectomy) is medically necessary ONLY in women WITHOUT known or strongly suspected uterine cancer, and ONLY for ONE of the following three indications: (1) premenopausal women who wish to maintain fertility AND who have no risk factors for uterine sarcoma; (2) premenopausal women who have clinical indications for hysterectomy AND who have no risk factors for uterine sarcoma, where a vaginal hysterectomy is technically difficult due to the large size of the uterus; OR (3) women with co-morbidities (e.g., cardiovascular, renal, hepatic, pulmonary, endocrine, or morbid obesity) where surgical alternatives to fibroid removal with power morcellation pose an unacceptable risk.; For power morcellation, 'risk factors for uterine sarcoma' that must be ABSENT (for indications 1 and 2) are defined as ANY of: history of 2 or more years of tamoxifen therapy; history of pelvic irradiation; history of childhood retinoblastoma; Lynch syndrome; or personal history of hereditary leiomyomatosis and renal cell carcinoma syndrome.; For power morcellation, the member MUST be informed of alternative procedures for fibroids and the risks of power morcellation in spreading unsuspected cancerous tissue beyond the uterus.. Applies to 3 codes: 58580, 58674, 37243.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: The following interventions are considered experimental, investigational, or unproven (not an all-inclusive list) because their safety and effectiveness have not been established: Other uses of transcatheter uterine artery embolization (except for the medically necessary uses listed above).; Experimental, investigational, or unproven for treatment of uterine fibroids: Acupuncture.; Experimental, investigational, or unproven for treatment of uterine fibroids: Cryomyolysis.; Experimental, investigational, or unproven for treatment of uterine fibroids: Cryotherapy.; Experimental, investigational, or unproven for treatment of uterine fibroids: Electrical ablation.; Experimental, investigational, or unproven for treatment of uterine fibroids: Interstitial thermotherapy.; Experimental, investigational, or unproven for treatment of uterine fibroids: Laparoscopic uterine artery occlusion.; Experimental, investigational, or unproven for treatment of uterine fibroids: Lasers.; Experimental, investigational, or unproven for treatment of uterine fibroids: Ultrasound (focused ultrasound) ablation, with or without magnetic resonance imaging (MRI) guidance (e.g., MR-guided focused ultrasound / ExAblate).; Fibroid removal with power morcellation is considered experimental, investigational, or unproven (i.e., NOT medically necessary) EXCEPT for the three specific indications listed in the medically necessary criteria; it is not appropriate in women with known or strongly suspected uterine cancer.; Power morcellation is contraindicated / not appropriate in peri- or post-menopausal women.; Power morcellation is contraindicated / not appropriate in women who are candidates for alternative surgical procedures allowing en bloc tissue removal (e.g., vaginal hysterectomy, mini-laparotomy).; Power morcellation is contraindicated / not appropriate in women with known or suspected uterine malignancy.; Uterine artery embolization is contraindicated in post-menopausal women with fibroid growth or rapid growth (which may indicate sarcoma development).; Uterine artery embolization is contraindicated in women with evidence of current genito-urinary infection and/or malignancy.; Uterine artery embolization is contraindicated in women who may wish to become pregnant in the future.; Uterine artery embolization is contraindicated in women with a history of prior pelvic X-ray (radiation) treatments, pelvic malignancy, chronic infections, or severe endometriosis. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0304 — Fibroid Treatment

Coverage criteria

  • Radiofrequency ablation (RFA) of uterine fibroids — open, laparoscopic (e.g., the Acessa System), or transcervical (e.g., the Sonata System) — is medically necessary as an alternative to hysterectomy or myomectomy when the member has persistence of ONE OR MORE symptoms directly attributed to uterine fibroids (i.e., ANY of): excessive menstrual bleeding (menorrhagia); bulk-related pelvic pain, pressure or discomfort; urinary symptoms referable to compression of the ureter or bladder; and/or dyspareunia.
  • Transcatheter uterine artery embolization (UAE) — e.g., by means of polyethylene glycol microspheres (HydroPearl) or tris-acryl gelatin microspheres (Embosphere Microspheres) — is medically necessary as an alternative to hysterectomy or myomectomy for the treatment of uterine fibroids when the member has persistence of ONE OR MORE symptoms directly attributed to uterine fibroids (i.e., ANY of): excessive menstrual bleeding (menorrhagia); bulk-related pelvic pain, pressure or discomfort; urinary symptoms referable to compression of the ureter or bladder; and/or dyspareunia.
  • Fibroid removal with power morcellation (myomectomy or hysterectomy) is medically necessary ONLY in women WITHOUT known or strongly suspected uterine cancer, and ONLY for ONE of the following three indications: (1) premenopausal women who wish to maintain fertility AND who have no risk factors for uterine sarcoma; (2) premenopausal women who have clinical indications for hysterectomy AND who have no risk factors for uterine sarcoma, where a vaginal hysterectomy is technically difficult due to the large size of the uterus; OR (3) women with co-morbidities (e.g., cardiovascular, renal, hepatic, pulmonary, endocrine, or morbid obesity) where surgical alternatives to fibroid removal with power morcellation pose an unacceptable risk.
  • For power morcellation, 'risk factors for uterine sarcoma' that must be ABSENT (for indications 1 and 2) are defined as ANY of: history of 2 or more years of tamoxifen therapy; history of pelvic irradiation; history of childhood retinoblastoma; Lynch syndrome; or personal history of hereditary leiomyomatosis and renal cell carcinoma syndrome.
  • For power morcellation, the member MUST be informed of alternative procedures for fibroids and the risks of power morcellation in spreading unsuspected cancerous tissue beyond the uterus.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Fibroid Treatment (CPT 58580), and what gets it denied?
Aetna CPB 0304 covers radiofrequency ablation (open, laparoscopic, or transcervical) and uterine artery embolization (UAE) as medically necessary alternatives to hysterectomy or myomectomy when the patient has at least one symptom directly attributed to uterine fibroids (heavy menstrual bleeding, bulk-related pelvic pain/pressure, urinary compression symptoms, or dyspareunia). Power morcellation is allowed only in narrow situations for women without known/suspected uterine cancer and is otherwise considered experimental, while focused ultrasound (MRgFUS), cryomyolysis, lasers, acupuncture and several other modalities are deemed experimental/investigational. Coverage criteria include: Radiofrequency ablation (RFA) of uterine fibroids — open, laparoscopic (e.g., the Acessa System), or transcervical (e.g., the Sonata System) — is medically necessary as an alternative to hysterectomy or myomectomy when the member has persistence of ONE OR MORE symptoms directly attributed to uterine fibroids (i.e., ANY of): excessive menstrual bleeding (menorrhagia); bulk-related pelvic pain, pressure or discomfort; urinary symptoms referable to compression of the ureter or bladder; and/or dyspareunia.; Transcatheter uterine artery embolization (UAE) — e.g., by means of polyethylene glycol microspheres (HydroPearl) or tris-acryl gelatin microspheres (Embosphere Microspheres) — is medically necessary as an alternative to hysterectomy or myomectomy for the treatment of uterine fibroids when the member has persistence of ONE OR MORE symptoms directly attributed to uterine fibroids (i.e., ANY of): excessive menstrual bleeding (menorrhagia); bulk-related pelvic pain, pressure or discomfort; urinary symptoms referable to compression of the ureter or bladder; and/or dyspareunia.; Fibroid removal with power morcellation (myomectomy or hysterectomy) is medically necessary ONLY in women WITHOUT known or strongly suspected uterine cancer, and ONLY for ONE of the following three indications: (1) premenopausal women who wish to maintain fertility AND who have no risk factors for uterine sarcoma; (2) premenopausal women who have clinical indications for hysterectomy AND who have no risk factors for uterine sarcoma, where a vaginal hysterectomy is technically difficult due to the large size of the uterus; OR (3) women with co-morbidities (e.g., cardiovascular, renal, hepatic, pulmonary, endocrine, or morbid obesity) where surgical alternatives to fibroid removal with power morcellation pose an unacceptable risk.; For power morcellation, 'risk factors for uterine sarcoma' that must be ABSENT (for indications 1 and 2) are defined as ANY of: history of 2 or more years of tamoxifen therapy; history of pelvic irradiation; history of childhood retinoblastoma; Lynch syndrome; or personal history of hereditary leiomyomatosis and renal cell carcinoma syndrome.; For power morcellation, the member MUST be informed of alternative procedures for fibroids and the risks of power morcellation in spreading unsuspected cancerous tissue beyond the uterus.. Applies to 3 codes: 58580, 58674, 37243. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: The following interventions are considered experimental, investigational, or unproven (not an all-inclusive list) because their safety and effectiveness have not been established: Other uses of transcatheter uterine artery embolization (except for the medically necessary uses listed above).; Experimental, investigational, or unproven for treatment of uterine fibroids: Acupuncture.; Experimental, investigational, or unproven for treatment of uterine fibroids: Cryomyolysis.; Experimental, investigational, or unproven for treatment of uterine fibroids: Cryotherapy.; Experimental, investigational, or unproven for treatment of uterine fibroids: Electrical ablation.; Experimental, investigational, or unproven for treatment of uterine fibroids: Interstitial thermotherapy.; Experimental, investigational, or unproven for treatment of uterine fibroids: Laparoscopic uterine artery occlusion.; Experimental, investigational, or unproven for treatment of uterine fibroids: Lasers.; Experimental, investigational, or unproven for treatment of uterine fibroids: Ultrasound (focused ultrasound) ablation, with or without magnetic resonance imaging (MRI) guidance (e.g., MR-guided focused ultrasound / ExAblate).; Fibroid removal with power morcellation is considered experimental, investigational, or unproven (i.e., NOT medically necessary) EXCEPT for the three specific indications listed in the medically necessary criteria; it is not appropriate in women with known or strongly suspected uterine cancer.; Power morcellation is contraindicated / not appropriate in peri- or post-menopausal women.; Power morcellation is contraindicated / not appropriate in women who are candidates for alternative surgical procedures allowing en bloc tissue removal (e.g., vaginal hysterectomy, mini-laparotomy).; Power morcellation is contraindicated / not appropriate in women with known or suspected uterine malignancy.; Uterine artery embolization is contraindicated in post-menopausal women with fibroid growth or rapid growth (which may indicate sarcoma development).; Uterine artery embolization is contraindicated in women with evidence of current genito-urinary infection and/or malignancy.; Uterine artery embolization is contraindicated in women who may wish to become pregnant in the future.; Uterine artery embolization is contraindicated in women with a history of prior pelvic X-ray (radiation) treatments, pelvic malignancy, chronic infections, or severe endometriosis. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Fibroid Treatment?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Fibroid Treatment?
Policy exclusions and limitations: The following interventions are considered experimental, investigational, or unproven (not an all-inclusive list) because their safety and effectiveness have not been established: Other uses of transcatheter uterine artery embolization (except for the medically necessary uses listed above).; Experimental, investigational, or unproven for treatment of uterine fibroids: Acupuncture.; Experimental, investigational, or unproven for treatment of uterine fibroids: Cryomyolysis.; Experimental, investigational, or unproven for treatment of uterine fibroids: Cryotherapy.; Experimental, investigational, or unproven for treatment of uterine fibroids: Electrical ablation.; Experimental, investigational, or unproven for treatment of uterine fibroids: Interstitial thermotherapy.; Experimental, investigational, or unproven for treatment of uterine fibroids: Laparoscopic uterine artery occlusion.; Experimental, investigational, or unproven for treatment of uterine fibroids: Lasers.; Experimental, investigational, or unproven for treatment of uterine fibroids: Ultrasound (focused ultrasound) ablation, with or without magnetic resonance imaging (MRI) guidance (e.g., MR-guided focused ultrasound / ExAblate).; Fibroid removal with power morcellation is considered experimental, investigational, or unproven (i.e., NOT medically necessary) EXCEPT for the three specific indications listed in the medically necessary criteria; it is not appropriate in women with known or strongly suspected uterine cancer.; Power morcellation is contraindicated / not appropriate in peri- or post-menopausal women.; Power morcellation is contraindicated / not appropriate in women who are candidates for alternative surgical procedures allowing en bloc tissue removal (e.g., vaginal hysterectomy, mini-laparotomy).; Power morcellation is contraindicated / not appropriate in women with known or suspected uterine malignancy.; Uterine artery embolization is contraindicated in post-menopausal women with fibroid growth or rapid growth (which may indicate sarcoma development).; Uterine artery embolization is contraindicated in women with evidence of current genito-urinary infection and/or malignancy.; Uterine artery embolization is contraindicated in women who may wish to become pregnant in the future.; Uterine artery embolization is contraindicated in women with a history of prior pelvic X-ray (radiation) treatments, pelvic malignancy, chronic infections, or severe endometriosis. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0304 — Fibroid Treatment

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0304 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.