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Blue Cross & Blue Shield of MississippiAll Plans · Coverage · Medical Policy · OB-GYNMedium impact

Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis

Effective date
Not stated in the notice
Identified
Jun 20, 2026

Summary

Laparoscopic or transcervical radiofrequency ablation (RFA) for symptomatic uterine fibroids is considered medically necessary in individuals 18 years and older when all of the policy criteria are met. The criteria include ultrasound evidence of fibroids less than 10 cm in diameter for laparoscopic RFA with Acessa or less than 7 cm for transcervical RFA with Sonata, a desire for a uterine-sparing approach or ineligibility for hysterectomy and other uterine-sparing alternatives, and at least one listed symptom caused directly by the fibroids. Other myolysis techniques, including laser or bipolar needles, cryomyolysis and magnetic resonance imaging-guided laser ablation, are considered investigational.

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What to do

Action · 5 steps
01Billing team: Before billing CPT 58580 or CPT 58674 for RFA, confirm and document that the individual is 18 years or older, that the fibroids meet the size limit for the device used, that the individual desires uterine-sparing treatment or is ineligible for hysterectomy or other uterine-sparing alternatives, and that at least one listed symptom is a direct result of the fibroids.
02BCBSMS makes no payment for services that are not documented to be medically necessary.
03For individuals over 45 years of age with menorrhagia or other abnormal bleeding, endometrial biopsy is recommended prior to treatment.
04Before billing CPT 58578, 58999, 76940, 76998 or 77022, review the member's specific benefit plan language, because the policy guidelines state that the Medical Policy Manual should not be used in lieu of that language.
05For Federal Employee Program members, the policy states that FDA-approved devices may not be considered investigational and may be assessed only on the basis of their medical necessity.

Codes mentioned

58580586745857858999769407699877022D25.0D25.9

Original notice

Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis
bcbsms.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Blue Cross & Blue Shield of Mississippi policiesOB-GYNCode 58580Code 58674Code 58578Code 58999Code 76940Code 76998Code 77022Code D25.0Code D25.9

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