ModifiedAmbetter NevadaPolicy CP.MP.106

Endometrial Ablation

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This policy governs medical necessity and coding for endometrial ablation using an FDA-approved device in patients with premenopausal abnormal uterine bleeding. Coverage applies when the specified clinical indications, diagnostic evaluations, anatomic requirements, and contraindication criteria are satisfied.

Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeModified

Effective DateNot specified

Last ReviewMar 1, 2023

Next Review DateNot specified

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

SourceLink

POLICY UPDATE CHANGES

The policy added a requirement that thyroid disorders must be treated or ruled out before endometrial ablation.

The policy removed the contraindication for previous classical cesarean or other transmural surgery.

The policy states that the current revision included minor rewording and background and table updates without additional clinical impact.

3Covered CPT procedure codes

7ICD-10-CM diagnosis codes supporting coverage

≥3 monthsRequired prior therapy for menorrhagia

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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

Get alerted when Policy CP.MP.106 changes without checking for updates manually.

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Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeModified

Effective DateNot specified

Last ReviewMar 1, 2023

Next Review DateNot specified

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

SourceLink

POLICY UPDATE CHANGES

The policy added a requirement that thyroid disorders must be treated or ruled out before endometrial ablation.

The policy removed the contraindication for previous classical cesarean or other transmural surgery.

The policy states that the current revision included minor rewording and background and table updates without additional clinical impact.

3Covered CPT procedure codes

7ICD-10-CM diagnosis codes supporting coverage

≥3 monthsRequired prior therapy for menorrhagia

Required androgen therapy in specified indication

Medical Necessity Criteria

Medically necessary endometrial ablation

Covered when all of the following criteria are met:

Medical necessity for FDA-approved endometrial ablation

Qualifying indication: The patient has menorrhagia unresponsive to at least three months of hormonal or medical therapy, unless such therapy is contraindicated; OR has abnormal uterine bleeding, including residual menstrual bleeding after at least six months of androgen therapy, in a member/enrollee with a female reproductive system undergoing treatment for gender affirmation.3 months or 6 months as applicable
Required evaluation and anatomic criteria: Cervical cytology or human papillomavirus (HPV) testing and gynecological examination exclude significant cervical disease; preprocedure endometrial sampling excludes malignancy or hyperplasia; no structural anomalies, such as fibroids or polyps, require transmural surgery or represent a contraindication to ablation; and thyroid disorders have been treated or ruled out.
Technique selection for weakened myometrium: If anatomic or pathologic conditions may result in a weakened myometrium, only a resectoscopic endometrial ablation is appropriate.
No contraindications: The patient is not premenopausal with future desire for fertility, does not have an untreated disorder of hemostasis, is not pregnant at the time of the procedure, does not have an intrauterine device at the time of the procedure, and does not have an active pelvic infection.

Insufficient evidence

Insufficient scientific evidence supports effectiveness for the following:

Insufficient-evidence services: Photodynamic endometrial ablation procedures or endometrial ablation for conditions other than the specified covered indications lack sufficient scientific evidence to support effectiveness.

Endometrial ablation is contraindicated when the patient is premenopausal and desires future fertility, has an untreated disorder of hemostasis, is pregnant at the time of the procedure, has an intrauterine device in place, or has an active pelvic infection.

When anatomic or pathologic conditions may result in a weakened myometrium, nonresectoscopic ablation techniques are excluded. In these circumstances, only resectoscopic endometrial ablation is appropriate.

Endometrial ablation for conditions other than the specified covered indications is not supported because there is insufficient scientific evidence to establish effectiveness.

Photodynamic endometrial ablation procedures are not supported because there is insufficient scientific evidence to establish effectiveness.

Covered Codes 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 therapy for menorrhagia

Minimum prior therapyAt least 3 months of hormonal or medical therapy

Clinical indicationMenorrhagia unresponsive to hormonal or medical therapy

ExceptionPrior therapy is not required when it is contraindicated

Androgen therapy and residual bleeding

Minimum androgen-therapy durationAt least 6 months

Clinical indicationResidual menstrual bleeding or abnormal uterine bleeding

Documentation and Coverage Safeguards

Documentation Required

Qualifying Indication and Prior Therapy

Document one qualifying indication and the required prior therapy before requesting coverage for endometrial ablation using an FDA-approved device.

Menorrhagia unresponsive to at least three months of hormonal or medical therapy, unless that therapy is contraindicated.
Abnormal uterine bleeding, including residual menstrual bleeding after at least six months of androgen therapy in a member/enrollee with a female reproductive system undergoing treatment for gender affirmation.

Documentation Required

Cervical Disease Evaluation

Document that cervical cytology or human papillomavirus (HPV) testing, together with a gynecological examination, excludes significant cervical disease.

Include the cervical cytology or HPV testing results and gynecological examination documentation in the clinical record.

Clinical Background

Endometrial ablation is a minimally invasive procedure that destroys the endometrial surface to reduce abnormal uterine bleeding in premenopausal patients while preserving the uterus. It is intended for patients who do not desire future fertility; pregnancy can still occur after ablation, so appropriate contraception counseling is important. Techniques include resectoscopic, or first-generation, procedures and nonresectoscopic, or second-generation, methods.

Key Terms and Techniques

Endometrial ablation

Procedure typeMinimally invasive surgical procedure

Clinical useUsed to treat premenopausal abnormal uterine bleeding

Method and outcomeTargets and destroys the endometrial surface while preserving the uterus

First-generation technique

GenerationFirst-generation endometrial ablation technique

ClassificationResectoscopic technique

Methods usedHysteroscopic or resectoscopic methods

Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeModified

Effective DateNot specified

Last ReviewMar 1, 2023

Next Review DateNot specified

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

SourceLink

On This Page

Applicable treatment context

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

Documentation Required

Endometrial Sampling Required

Document that endometrial sampling was completed before the procedure and excluded malignancy or hyperplasia.

Include the preprocedure sampling report or other documentation demonstrating that malignancy and hyperplasia were excluded.

Documentation Required

Anatomic and Thyroid Assessment

Assess the uterine anatomy and document that structural or pathologic conditions do not contraindicate the planned procedure. Treat or rule out thyroid disorders before ablation.

Document that there are no structural anomalies, such as fibroids or polyps, requiring transmural surgery or representing a contraindication to ablation.
If an anatomic or pathologic condition may result in a weakened myometrium, only resectoscopic endometrial ablation is appropriate.
Document that thyroid disorders have been treated or ruled out.

Billing Rule

Review Medicare Coverage Guidance

For Medicare members/enrollees, review all applicable Medicare coverage guidance before applying the criteria in this clinical policy.

Review applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles.
Refer to the CMS website for additional Medicare coverage information.

Billing Rule

Check State Medicaid Provisions

For Medicaid members/enrollees, applicable state Medicaid coverage provisions take precedence when they conflict with this clinical policy.

Refer to the applicable state Medicaid manual for coverage provisions pertaining to endometrial ablation.

Denial Risk

Failure to Meet Medical-Necessity Criteria

Endometrial ablation using an FDA-approved device is medically necessary only when all specified criteria are met. Deny or do not approve the procedure when the device is not FDA approved or when required criteria or contraindication safeguards are not satisfied.

Confirm a qualifying indication and required prior therapy.
Confirm cervical disease has been excluded and preprocedure endometrial sampling has excluded malignancy or hyperplasia.
Confirm appropriate anatomic assessment, thyroid evaluation, and procedure selection when the myometrium may be weakened.
Do not proceed when contraindications are present, including desire for future fertility in a premenopausal member, untreated hemostasis disorders, pregnancy, an intrauterine device in place, or active pelvic infection.

Denial Risk

Insufficient-Evidence Procedures or Indications

There is insufficient scientific evidence to support photodynamic endometrial ablation or ablation for conditions other than the specified qualifying indications.

Photodynamic endometrial ablation procedures are not supported.
Endometrial ablation for any condition other than the specified qualifying indications is not supported.

Second-generation technique

GenerationSecond-generation endometrial ablation technique

ClassificationNonresectoscopic method

Devices and energy sourcesUses devices and energy sources other than resectoscopic techniques