Does Health Insurance Cover Fibroid Treatment?

Fibroids are growths that form in the uterus and are generally not cancerous. About 70% or more women develop fibroids by age 50. These growths are most common in those in their 40s and early 50s. Many people who have fibroids don’t have symptoms. However, some may experience heavy, painful periods, pelvic pressure, and frequent urination, leading to procedures to remove or shrink the fibroids. With so many impacted, there is a need to understand what medical costs health insurance covers for fibroid treatment.

Types of fibroid removal treatments

There are several types of treatment for fibroids. Your healthcare provider may make treatment recommendations based on a few factors, including:

  • Whether you have any symptoms
  • If you want to get pregnant
  • The size of the fibroids
  • Where the fibroids are located
  • Your age, and if you’re close to menopause

If fibroids cause no symptoms, treatment may be unnecessary other than checking at regular visits to see if they've enlarged.

Over-the-counter pain relievers like ibuprofen or acetaminophen can help relieve mild pain. Some birth control pills or shots can lighten your periods and ease symptoms. An IUD (intrauterine device) called Mirena may also help manage heavy bleeding. To shrink fibroids, your healthcare provider may recommend hormone drugs called gonadotropin-releasing hormone agonists (GnRHa).

When symptoms are moderate to severe, surgery may be necessary. Options include:

  • Myomectomy. This procedure involves the surgical removal of the fibroids but not the uterus.
  • Hysterectomy. A hysterectomy is the removal of the uterus. It’s often done when fibroids are large or other treatments do not work. Fibroids are the primary reasons a hysterectomy may be performed. There are different types of hysterectomy.
  • Endometrial ablation. This procedure involves the removal or destruction of the uterine lining to control heavy bleeding.
  • Myolysis. This procedure destroys the fibroid tumors using electricity or freezing cold.

Uterine Fibroid Embolization (UFE) or Uterine Artery Embolization (UAE) is a minimally invasive procedure that shrinks fibroids by cutting off their blood supply.

How much does fibroid removal cost?

The cost of fibroid removal varies depending on the procedure type. A hysterectomy may cost $10,000 to about $22,000. However, the type of hysterectomy impacts costs, too. For example, a minimally invasive type of hysterectomy — a laparoscopic vaginal hysterectomy — can be less expensive at nearly $3,400, based on Medicare.gov.

Removing the fibroids during a myomectomy may cost about $2,000 to $3,400, depending on the approach, according to Medicare.gov. A Journal of Vascular and Interventional Radiology study examined uterine artery embolization costs. The average price for UAE was close to $11,620.

In addition to the type of procedure, the cost of fibroid removal also depends on other factors. These include what providers in your area charge, using hospital versus office facilities, getting surgery as an inpatient or outpatient, extra tests needed, and what region you live in.

Does health insurance cover fibroid removal?

Most health insurance plans cover some type of fibroid treatment. However, each insurance company sets its own rules on what procedures they will pay for. For example, if you have uterine fibroids and are experiencing heavy periods, pelvic pain, or bladder issues, Aetna may cover treatments like uterine artery embolization or radiofrequency ablation as an alternative to a hysterectomy or myomectomy. United Healthcare may cover the costs of UAE to treat fibroids that cause symptoms.

Some insurance plans only cover surgical procedures like a hysterectomy, but only after you’ve tried other treatments that did not relieve symptoms. However, some health plans may consider specific treatment methods, experimental and investigational. This means they may not pay for them.

Even with health insurance coverage, you may still have some out-of-pocket costs for fibroid removal. These can include:

  • Doctor visit copays
  • Prescription medication copays
  • Hospital or surgery copays
  • Coinsurance costs for your share of the covered services

Be sure to check your specific plan’s coverage details and understand what costs you may still be responsible for paying.

Do I need to get prior authorization for fibroid treatments?

Whether you need prior authorization for fibroid removal depends on your specific health insurance plan. Rules differ between plan types like health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Rules may also vary based on your insurer.

Significant procedures like fibroid surgery or planned hospital stays often require prior authorization. Your healthcare provider may also need to obtain prior authorization for specific tests related to fibroid removal. With approval upfront, your insurer may cover the medical expenses later.

Contact your health plan or benefits manager before undergoing fibroid treatment to understand the rules. They can explain the prior authorization process, confirm which specific treatments require insurance prior authorization, and tell you what documents are needed. Knowing these rules protects you from claims denials later.

Questions to ask your health insurance before fibroid removal

Before undergoing fibroid removal procedures, contact your health insurance plan to get clear answers to key questions like:

  • What types of fibroid removal procedures do you cover?
  • Are there deductibles, copays, or coinsurance fees for fibroid surgery?
  • Do I need prior authorization for any fibroid removal procedures?
  • Do I have to use certain hospitals or surgeons for the maximum coverage?
  • Are there exclusions and limitations on the covered treatments?
  • Are nonsurgical options like hormone medications to shrink fibroids covered?
  • How can I check if my doctor or specialist is in-network under my plan?
  • What approval paperwork or forms must be submitted before surgery to get coverage?

What do I do if my fibroid removal claim is denied?

Health insurance companies may sometimes deny your fibroid removal claim, even if your healthcare provider recommended the treatment. Typical reasons for claim denials include the insurer deciding the procedure was not 'medically necessary,' that it was 'investigational' or 'experimental,' or that proper prior authorizations and forms were not complete before surgery.

If your claim to cover fibroid removal gets denied, you generally have the right to appeal the decision. First, review your Explanation of Benefits (EOB) to review the reason for the denial. Call your health plan to obtain more information on the denial and understand how to begin the appeal process. Then, submit a written appeal letter with strong support from your healthcare provider that the treatment provided was reasonable and necessary. Include all relevant medical records supporting your case.

Typically, the appeal response should come within 60 days once you submit all the needed information. This timeline applies if you already had the fibroid removal procedure done.

Most health insurance plans cover fibroid treatment. However, the treatments covered and who qualifies vary by health insurers. A hysterectomy is often done because of fibroids and is generally covered by health plans. Some fibroid treatments may be considered experimental or investigational by some health plans. Before treatment, call your health insurance to ask questions and potentially avoid a denied claim.

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