ModifiedAmbetter NevadaPolicy CP.MP.106

Endometrial Ablation

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Medical necessity and coverage criteria for FDA-approved endometrial ablation in premenopausal abnormal uterine bleeding, including specified residual bleeding during gender-affirming treatment.

Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeModified

Effective DateN/A

Last ReviewMar 1, 2023

Next Review DateN/A

Key ActionDocument that thyroid disorders have been treated or ruled out before endometrial ablation.

SourceLink

POLICY UPDATE CHANGES

The March 2023 revision added a requirement that thyroid disorders be treated or ruled out before endometrial ablation.

The March 2023 revision removed previous classical cesarean or other transmural surgery from the listed contraindications.

2Covered indication pathways

3 monthsMenorrhagia therapy minimum

6 monthsAndrogen therapy minimum

5Listed contraindications

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ModifiedAmbetter NevadaPolicy CP.MP.106

Endometrial Ablation

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Sign up for Ambetter Nevada Policy CP.MP.106 alerts

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Medical necessity and coverage criteria for FDA-approved endometrial ablation in premenopausal abnormal uterine bleeding, including specified residual bleeding during gender-affirming treatment.

Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeModified

Effective DateN/A

Last ReviewMar 1, 2023

Next Review DateN/A

Key ActionDocument that thyroid disorders have been treated or ruled out before endometrial ablation.

SourceLink

POLICY UPDATE CHANGES

The March 2023 revision added a requirement that thyroid disorders be treated or ruled out before endometrial ablation.

The March 2023 revision removed previous classical cesarean or other transmural surgery from the listed contraindications.

2Covered indication pathways

3 monthsMenorrhagia therapy minimum

6 monthsAndrogen therapy minimum

5Listed contraindications

3CPT procedure codes

7ICD-10-CM diagnosis codes

Medical Necessity and Coverage Criteria

Initial coverage and evidence limitations

Covered when all of the following criteria are met:

Medical necessity requirements

Qualifying indication
- Menorrhagia is unresponsive to at least three months of hormonal or medical therapy, unless such therapy is contraindicated.At least 3 months
- Abnormal uterine bleeding during gender affirmation: Abnormal uterine bleeding, including residual menstrual bleeding after at least six months of androgen therapy, occurs in a member/enrollee with a female reproductive system undergoing treatment for gender affirmation.At least 6 months of androgen therapy
Cervical disease excluded: Cervical cytology or human papillomavirus (HPV) testing and gynecological examination exclude significant cervical disease.
Malignancy and hyperplasia excluded: Endometrial sampling before the procedure excludes malignancy or hyperplasia.
No contraindicating structural anomaly: There are no structural anomalies, such as fibroids or polyps, that require transmural surgery or represent a contraindication to ablation.
Resectoscopic technique when myometrium is weakened: If anatomic or pathologic conditions may result in a weakened myometrium, only a resectoscopic endometrial ablation is appropriate.
Thyroid disorders addressed: Thyroid disorders have been treated or ruled out.
No listed contraindications: The patient does not have any of the following contraindications: premenopausal status with future desire for fertility; untreated disorders of hemostasis; pregnancy at the time of the procedure; an intrauterine device at the time of the procedure; or active pelvic infection.
All listed contraindications must be absent.

Insufficient-evidence exclusions: The policy does not support effectiveness for photodynamic endometrial ablation procedures or for endometrial ablation used to treat conditions other than the specified menorrhagia or abnormal uterine bleeding indications.

These services are excluded because of insufficient scientific evidence.

Photodynamic endometrial ablation is excluded because the policy finds insufficient scientific evidence to support its effectiveness.

Endometrial ablation is excluded when used to treat conditions other than the specified qualifying indications: menorrhagia unresponsive to at least 3 months of hormonal or medical therapy, unless that therapy is contraindicated, or abnormal uterine bleeding, including residual menstrual bleeding after at least 6 months of androgen therapy during gender-affirming treatment. The policy finds insufficient scientific evidence to support effectiveness for other conditions.

Medical necessity is not established unless an eligible indication is documented and the procedure uses an FDA-approved device. Required evaluation must exclude significant cervical disease through cervical cytology or HPV testing and gynecological examination, and exclude endometrial malignancy or hyperplasia through preprocedure sampling. There must be no structural abnormality, such as a fibroid or polyp, requiring transmural surgery or otherwise contraindicating ablation; when anatomic or pathologic conditions may weaken the myometrium, only resectoscopic ablation is appropriate. Thyroid disorders must be treated or ruled out, and the patient must have none of the listed contraindications: future fertility desire, untreated hemostasis disorder, pregnancy at the time of the procedure, an intrauterine device at the time of the procedure, or active pelvic infection.

Coding and Therapy Requirements

Covered CPT CodesCPTCovered

58353	Endometrial ablation, thermal, without hysteroscopic guidance
58356	Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
58563	Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)

Covered ICD-10-CM Diagnosis Codes That Support Coverage CriteriaICD-10Covered

N92.0	Excessive and frequent menstruation with regular cycle
N92.1	Excessive and frequent menstruation with irregular cycle
N92.4	Excessive bleeding in the premenopausal period
N92.5	Other specified irregular menstruation
N92.6	Irregular menstruation, unspecified
N93.8	Other specified abnormal uterine and vaginal bleeding
N93.9	Abnormal uterine and vaginal bleeding, unspecified

Prior hormonal or medical therapy for menorrhagia

Qualifying conditionMenorrhagia

Required prior therapyHormonal or medical therapy

Minimum durationAt least 3 months

Treatment responseMenorrhagia must be unresponsive to the therapy, unless the therapy is contraindicated

Androgen therapy for residual menstrual bleeding during gender affirmation

Qualifying conditionAbnormal uterine bleeding, including residual menstrual bleeding

Documentation and Denial Risks

Step Therapy

Document failed prior therapy

For menorrhagia, document that the member was unresponsive to at least three months of hormonal or medical therapy, unless such therapy is contraindicated.

Step Therapy

Document residual bleeding after androgen therapy

For abnormal uterine bleeding during gender affirmation, document residual menstrual bleeding after at least six months of androgen therapy in a member or enrollee with a female reproductive system.

Documentation Required

Document the qualifying indication

Establish and document one qualifying indication and the applicable treatment history. For menorrhagia, include the duration and response to at least three months of hormonal or medical therapy, unless contraindicated; for gender-affirming treatment, document residual menstrual bleeding after at least six months of androgen therapy.

Clinical Background

Endometrial ablation is a minimally invasive procedure that destroys the endometrial surface to reduce abnormal uterine bleeding in premenopausal patients. It preserves the uterus and is intended for patients who do not desire future fertility.

Key Definitions

Endometrial ablation

Procedure typeMinimally invasive surgical procedure

Primary useTreats premenopausal abnormal uterine bleeding

MethodTargeted destruction of the endometrial surface

Uterine effectPreserves the uterus

FDA-approved endometrial ablation

Device requirementPerformed with an FDA-approved device

Resectoscopic techniqueIncludes first-generation resectoscopic techniques

Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeModified

Effective DateN/A

Last ReviewMar 1, 2023

Next Review DateN/A

Key ActionDocument that thyroid disorders have been treated or ruled out before endometrial ablation.

SourceLink

On This Page

A member/enrollee with a female reproductive system undergoing treatment for gender affirmation

Required therapyAndrogen therapy

Minimum durationAt least 6 months

Coverage requirementBleeding must remain after the required androgen therapy

Menorrhagia unresponsive to at least three months of hormonal or medical therapy, unless contraindicated.
Abnormal uterine bleeding with residual menstrual bleeding after at least six months of androgen therapy during gender affirmation.

Documentation Required

Complete cervical and endometrial evaluation

Submit cervical cytology or HPV testing and gynecological examination results excluding significant cervical disease. Also provide preprocedure endometrial sampling results excluding malignancy or hyperplasia.

Cervical cytology or HPV testing
Gynecological examination
Preprocedure endometrial sampling

Documentation Required

Assess contraindications and comorbidities

Document assessment for structural uterine abnormalities and thyroid disorders, and confirm that all listed contraindications are absent before the procedure.

Structural anomalies, including fibroids or polyps that require transmural surgery or contraindicate ablation
Thyroid disorders treated or ruled out
Pregnancy at the time of procedure
Intrauterine device at the time of procedure
Active pelvic infection
Untreated disorders of hemostasis
Premenopausal status with future desire for fertility

Denial Risk

Avoid medical-necessity denial

Endometrial ablation may be denied if it does not use an FDA-approved device, if a covered indication is not established, or if any required medical-necessity criterion is not met.

Use an FDA-approved device.
Establish a covered indication.
Meet all required medical-necessity criteria.

Denial Risk

Avoid insufficient-evidence indications

Coverage may be denied for photodynamic endometrial ablation or for ablation used to treat conditions other than the specified menorrhagia or abnormal uterine bleeding indications because the policy finds insufficient scientific evidence to support effectiveness.

Photodynamic endometrial ablation procedures
Endometrial ablation for conditions other than the specified qualifying indications

Denial Risk

Resolve contraindicating findings

Coverage may be denied when significant cervical disease, endometrial malignancy or hyperplasia, contraindicating structural abnormalities, untreated or unruled-out thyroid disease, or any listed contraindication is present.

Significant cervical disease
Endometrial malignancy or hyperplasia
Structural anomalies that require transmural surgery or contraindicate ablation
Thyroid disorders that have not been treated or ruled out
Pregnancy, an intrauterine device, active pelvic infection, untreated hemostasis disorder, or future fertility desire

Nonresectoscopic techniqueIncludes second-generation nonresectoscopic methods

Clinical useUsed for endometrial ablation to treat premenopausal abnormal uterine bleeding