Provider Notice issued 05/07/2024

The Department is pleased to announce that the claims processing application has been restored as of March 23, 2024.

This notice expands upon the Department of Healthcare and Family Services’ (HFS) recent coverage of CPT code 58580 - Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency. The coverage guidance applies to the Medicaid fee-for-service (FFS) program and HealthChoice Illinois (HCI) managed care organizations (MCOs).

Transcervical Fibroid Ablation (TFA) is a Food and Drug Administration (FDA)-approved procedure and a less invasive option for treatment of symptomatic uterine fibroids, not requiring surgical incisions or general anesthesia. Below is coverage guidance gathered from American College of Obstetrics and Gynecology (ACOG), American Association of Gynecologic Laparoscopists (AAGL), other peer-reviewed publications, and consultations with gynecologists practicing in Illinois communities.

For the FFS program, HFS does not require prior approval (PA) for this procedure. Contact the applicable MCO for any specific PA requirements.

Coverage Guidance: 

Before the procedure, physicians should review and document the following in the medical record:

   ·Patient’s age between 18 and 50 years
   ·Evidence of uterine fibroids via ultrasound that are less than 7 cm in diameter
   ·Patient desires a uterine-sparing treatment
   ·Patient’s signed informed consent to undergo TFA following discussion of available alternatives, potential benefits and complications including some known and      some unknown safety risks including an adverse outcome in case of a future pregnancy
    ·The procedure will be performed by a properly trained, and experienced physician
    ·Absent history of previous TFA procedure

Indication of at least 1 of the following symptoms attributed to fibroid(s):

    · Menorrhagia or other abnormal uterine bleeding that interferes with daily activities or causes anemia (Hb less than 11 or Hct less than 33)
     ·Pelvic pain or pressure
     ·Urinary symptoms: frequency or urgency due to compression of bladder
     ·Gastrointestinal symptoms: constipation or bloating due to compression of bowel
     ·Dyspareunia (painful or difficult sexual relations)

Absence of any of the following contraindications to this procedure:

     ·Current pregnancy, or a planned pregnancy in the near future
     ·Known or suspected endometrial hyperplasia or cancer
     · Active pelvic infection
      ·Intrauterine device (IUD), or an abdominal metallic transplant in place
      ·Previous uterine surgery
      ·Postmenopausal state
      ·Congenital uterine anomalies (e.g., bicornuate uterus)
      ·Uterine cavity length greater than 10 cm
       ·Allergy to nickel

All medical records may be subject to audit.

Questions regarding this notice may be directed to a physician billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 or the applicable MCO.

Kelly Cunningham, Administrator
Division of Medical Programs