Medical policy: Noncontraceptive Use of Intrauterine Devices (IUDs)

Policy number: MP 7.026

Effective date: 6/1/2026

Policy

NOTE: For the use of intrauterine devices for contraceptive purposes - refer to the Benefit Booklet and Preventive Benefits.

Intrauterine devices (IUDs) may be medically necessary for non-contraceptive uses for the following indications:

• As indicated by the Food and Drug (FDA) label information, use of levonorgestrel intrauterine systems (LNG IUS) devices containing 52 mg levonorgestrel (Mirena®, Liletta®) may be considered medically necessary to treat heavy menstrual bleeding in individuals who use intrauterine contraception as their method of pregnancy prevention.
• Off-label use of levonorgestrel intrauterine systems (LNG IUS) devices containing 52 mg levonorgestrel (Mirena®, Liletta®) for conditions other than specified in the FDA label information above may be considered medically necessary for the following:
  • As an alternative to other hormonal regimens (oral contraceptives, cyclic or continuous progestin’s, etc.) or as a treatment option to surgical interventions in an individual who has excessive or irregular bleeding defined as one of the following:
    • Idiopathic menorrhagia: Excessively heavy, regular menses in the absence of intracavitary pathology or coagulopathy; OR
    • Menometrorrhagia: Bleeding that is excessive in amount, is prolonged in duration, and may occur at regular or irregular intervals.
  • As an alternative delivery system to protect against endometrial hyperplasia in individuals who are currently receiving selective estrogen receptor modulators.
  • Management of recurrent pelvic pain secondary to multi-treated endometriosis.

Levonorgestrel intrauterine systems (LNG IUS) devices containing less than 52 mg levonorgestrel (Skyla™, Kyleena™) for off-label non-contraceptive use are considered investigational. There is insufficient evidence to support a conclusion concerning the general health outcomes or benefits associated with this procedure.

The non-contraceptive use of IUDs for indications other than those described in the policy criteria are considered investigational as there is insufficient evidence to support a conclusion concerning the general health outcomes or benefits associated with this procedure.

Removal of an IUD for medical conditions such as unexplained abnormal uterine bleeding or pregnancy may be considered medically necessary.

Cross-references:

MP 2.103 Off Label Use of Medications
MP 7.013 Endometrial Ablation

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Intrauterine devices (IUDs) are devices that are inserted in the uterus to prevent effective conception. IUDs can be classified as non-hormonal (e.g., ParaGard® copper IUD) or hormonal. Hormonal devices include levonorgestrel-releasing intrauterine systems (LNG-IUS) like Mirena®, Liletta®, Skyla® and Kyleena®.

The U.S. Food and Drug Administration (FDA) approved Mirena® (levonorgestrel-releasing intrauterine system) 52 mg, a hormone-releasing system to prevent pregnancy for up to 8 years and treatment of heavy menstrual bleeding for 5 years.

The U.S. Food and Drug Administration (FDA) approved Skyla™ (levonorgestrel-releasing intrauterine system) 13.5 mg, a hormone-releasing system that is placed in the uterus for the prevention of pregnancy for up to three years. No studies have been completed for the use of Skyla™ for the treatment of heavy menstrual bleeding.

The U.S. Food and Drug Administration (FDA) approved Liletta® (levonorgestrel-releasing intrauterine system) 52 mg, a hormone-releasing system to prevent pregnancy for up to 8 years and treatment of heavy menstrual bleeding for 5 years.

The U.S. Food and Drug Administration (FDA) approved Kyleena® (levonorgestrel-releasing intrauterine system) 19.5 mg, a hormone-releasing system to prevent pregnancy for up to 5 years. No studies have been completed for the use of Kyleena® for the treatment of heavy menstrual bleeding.

Rationale

Employing an IUD for heavy menstruation can reduce symptoms of cramping and pain and reduce associated comorbidities, such as anemia.

The use of LNG IUS devices for dysfunctional uterine bleeding may also allow women to avoid more invasive procedures such as hysterectomy or endometrial ablation.

Definitions

Dysfunctional Uterine Bleeding (DUB) is abnormal bleeding from the uterus not caused by tumor, inflammation, or pregnancy.

Menorrhagia is excessive uterine bleeding occurring at the regular intervals of menstruation, the period of flow being of greater than usual duration.

Off-label Use is the use of a prescription drug or medical device in the treatment of an illness or injury for which it has not been specifically approved by the FDA.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Investigational; therefore, not covered when used for any indication other than contraception:

Covered when medically necessary:

References

1. Abou-Setta AM, Al-Inany HG, Farquhar CM. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005072. DOI: 10.1002/14651858.CD005072.pub2. Update in: Cochrane Database Syst Rev. 2013; 1:CD005072. PMID: 17054236
2. American College of Obstetricians and Gynecologists (ACOG). Dysmenorrhea and Endometriosis in the Adolescent. Committee Opinion 760. December 2018.
3. American College of Obstetricians and Gynecologists (ACOG). Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Practice Bulletin 186. November 2017 (Reaffirmed 2021).
4. Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf A. Treatment of menorrhagia. Am Fam Physician. 2007 Jun 15; 75(12): 1813-9. PMID: 17619523
5. Bahamondes L, Petta CA, Fernandes A, Monteiro I. Use of the levonorgestrel-releasing intrauterine system in women with endometriosis, chronic pelvic pain, and dysmenorrhea. Contraception. 2007 Jun; 75(6 Suppl): S134-9. Epub 2007 Feb 16. PMID: 17531605
6. Beatty M, Blumenthal P. The levonorgestrel-releasing intrauterine system: Safety, efficacy, and patient acceptability. Ther Clin Risk Manag. 2009 Jun;5(3):561-574. PMID 19707273.
7. Behera M. Abnormal (Dysfunctional) Uterine Bleeding. Article 257007. eMedicine. Updated January 29, 2026.
8. Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician 2005; 71(1): 95-102. PMID: 1566031
9. Kaunitz, Andrew M. Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics). In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated May 23, 2024. Literature review current through Jan 2026.
10. Lethaby AE, Cooke I, Rees M. Progesterone/progestogen releasing intrauterine systems versus either placebo or any other medication for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; (4): CD002126. Cochrane Database Syst Rev. 2015 Apr 30 ;(4): CD002126. doi: 10.1002/14651858.CD002126.pub3. Update in: Cochrane Database Syst Rev. 2020 Jun 12; 6:CD002126. PMID: 25924648
11. Reed S, Urban R. Management of Endometrial Hyperplasia : Management and Prognosis. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated September 24, 2025. Literature review current through Jan 2026.
12. Reid, PC, Virtanen-Kari, S. Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss, and pictorial blood loss assessment charts. BJOG 2005; 112:1121. Aug; 112(8):1121-5. doi: 10.1111/j.1471-0528.2005.00642.x. PMID: 16045528
13. Schaedel ZE, Dolan G, Powell MC. The use of the levonorgestrel-releasing intrauterine system in the management of menorrhagia in women with hemostatic disorders. Am J Obstet Gynecol. 2005; 193(4):1361-1363. doi:10.1016/j.ajog.2005.05.002
14. Shaw RW, Symonds IM, Tamizian O, Chaplain J, Mukhopadhyay S. Randomised comparative trial of thermal balloon ablation and levonorgestrel intrauterine system in patients with idiopathic menorrhagia. Aust N Z J Obstet Gynaecol. 2007; 47(4):335-340. doi:10.1111/j.1479-828X.2007.00747.x
15. Kaunitz, Andrew M. Abnormal Uterine Bleeding in Nonpregnant Reproductive-Age Patients: Management. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated December 18, 2025. Literature review current through Jan 2026.