ModifiedAmbetter NevadaPolicy CP.MP.106

Endometrial Ablation

Medical necessity guidelines for endometrial ablation using FDA-approved devices for non-Medicare health plans affiliated with Centene (Ambetter Nevada), including indications, contraindications, and coding references affecting coverage decisions.

Policy Summary

PayerAmbetter Nevada

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeClinical and operational revisions

Effective Date

Next Review Date

Key ActionObtain prior authorization when billing CPT 58353, 58356, or 58563 and document indication, prior medical therapy trial, cervical screening, and endometrial sampling.

SourceLink

POLICY UPDATE CHANGES

Added note to policy to refer to MC.CP.MP.106 for Medicare criteria and specified 'non-Medicare' health plans in Policy/Criteria I. and II.

Added requirement that thyroid disorders have been treated or ruled out prior to ablation.

Expanded contraindications to explicitly include active pelvic infection or recent uterine infection, endometrial hyperplasia or uterine cancer, and post-menopausal status.

Updated contraindication regarding intrauterine device for clarity (I.G.4) and removed contraindication of recent pregnancy from I.G.7.

3 codesReferenced CPT codes

N92.x / N93.xSupporting ICD-10 codes

MultipleDevice techniques listed

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Coverage Criteria for Endometrial Ablation

Initial Therapy / Coverage Criteria

Covered when ALL of the following are met for non-Medicare plans affiliated with Centene:

Primary coverage criteria (I)

I.A Indication
- I.A.1 Menorrhagia: Menorrhagia unresponsive to hormonal or medical therapy (unless contraindicated).
- I.A.2 Transgender care: 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.6 months androgen therapy
I.B Cervical screening: Cervical cytology or human papillomavirus (HPV) testing and gynecological exam excludes significant cervical disease.
I.C Endometrial sampling: Endometrial sampling prior to the procedure has excluded malignancy or hyperplasia.
I.D Structural anomalies: No structural anomalies, such as fibroids or polyps, that require transmural surgery or represent a contraindication to an ablation procedure.
I.E Myometrial weakness: If anatomic or pathologic conditions exist that may result in a weakened myometrium, only a resectoscopic endometrial ablation is appropriate.
I.F Thyroid disorders: Thyroid disorders have been treated or ruled out prior to the procedure.
I.G Contraindications absence: Member does not have any of the listed contraindications.
Contraindications: premenopausal with desire for future fertility; untreated disorders of hemostasis; pregnancy at time of procedure; intrauterine device unless device will be removed during procedure; active pelvic or recent uterine infection; endometrial hyperplasia or uterine cancer; post-menopausal.

Insufficient Evidence

Not covered / insufficient evidence:

II Insufficient evidence

Photodynamic ablation: Photodynamic endometrial ablation procedures.
Other indications: Endometrial ablation for treatment of conditions other than those specified in the coverage criteria.

Photodynamic endometrial ablation is specifically identified in the policy as a procedure for which there is insufficient scientific evidence to support effectiveness and therefore is not supported for coverage under non‑Medicare plans affiliated with Centene. The policy lists photodynamic endometrial ablation under the Insufficient Evidence section as an excluded technique, along with a general statement that ablation for indications other than those specified in the coverage criteria is likewise not supported.

Coverage determinations made under this policy are guides to medical necessity and do not guarantee payment. All coverage decisions and benefit administration remain subject to the terms, conditions, exclusions, and limitations of the member’s coverage documents (for example, evidence of coverage or certificate of coverage) and to applicable state and federal requirements; plan‑level administrative rules and prior authorization requirements also apply. Providers should verify member eligibility, plan benefits, and any plan‑specific prior authorization rules before scheduling procedures.

The policy lists specific contraindications that make endometrial ablation not medically necessary. These include desire for future fertility (premenopausal patients who want future fertility), untreated disorders of hemostasis, pregnancy at the time of the procedure, an intrauterine device (IUD) that will not be removed during the procedure, active pelvic or recent uterine infection, endometrial hyperplasia or uterine cancer, and post‑menopausal status. The policy also requires that thyroid disorders be treated or ruled out prior to the procedure as part of pre‑procedure evaluation.

Coding and Device Information

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).

Diagnosis Codes that Support CoverageICD-10

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.

Device-specific treatment time and amenorrhea rates

HydroThermAblator (Heated free fluid)Treatment time ≈ 14 minutes (3 min heat to 90°C, 10 min ablation, ~1 min cool-down); reported amenorrhea rate 71%.

NovaSure (Radiofrequency electricity)Treatment time ≈ 1.5 minutes; reported amenorrhea rate 41%.

Mara (Vapor ablation)Treatment time ≈ 2.0 minutes; amenorrhea rate not specified in table.

Cerene (Cryotherapy)Treatment time 8–10 minutes; reported amenorrhea rate 53%.

Minerva (Combined thermal and bipolar radiofrequency)Treatment time ≈ 2.0 minutes; amenorrhea rate not specified in table.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for endometrial ablation when billing CPT codes 58353, 58356, or 58563. Providers must demonstrate that all medical necessity criteria are met prior to the procedure.

Prior authorization required for CPT 58353, 58356, 58563
Submit documentation showing all medical necessity criteria are met

Note

Check Applicable NCD/LCD and State Medicaid Provisions

Before applying this policy's criteria, check applicable Medicare NCDs and LCDs and state Medicaid coverage provisions; state Medicaid rules take precedence for Medicaid members. Review CMS and state Medicaid resources when appropriate.

Verify Medicare NCDs/LCDs and Medicare Coverage Articles at http://www.cms.gov
For Medicaid members, follow state Medicaid manual when conflicts exist

Background and Evidence Summary

Endometrial ablation is described as a minimally invasive uterine‑preserving procedure intended to treat abnormal uterine bleeding in premenopausal patients who do not desire future fertility. The policy distinguishes between first‑generation resectoscopic techniques and second‑generation nonresectoscopic device methods and notes that ablation may reduce bleeding or achieve amenorrhea but is not definitive—hysterectomy remains the definitive treatment and ablation outcomes can be limited by conditions such as adenomyosis, leiomyomata, or endometriosis. Contraception counseling is advised because pregnancy can still occur after ablation.

Definitions and Technique Classification

Endometrial ablation — definition and contraindications

DefinitionTargeted destruction of the endometrial surface of the uterine cavity using various energy sources while preserving the uterus.

Fertility considerationIndicated for premenopausal patients who have no desire for future fertility; pregnancy can occur after ablation and contraception counseling is recommended.

Contraindications (summary)Includes desire for future fertility, untreated bleeding disorders, pregnancy at time of procedure, IUD not removed, active pelvic or recent uterine infection, endometrial hyperplasia or uterine cancer, and post‑menopausal status.

Technique classification and device-specific modalities

Technique classificationTwo major classifications: first‑generation resectoscopic techniques and second‑generation nonresectoscopic methods.

First‑generation (resectoscopic) examples