Endometrial Ablation
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Medical necessity guidelines for endometrial ablation for non‑Medicare health plans affiliated with Centene Corporation/AZ Complete Health, describing indications, contraindications, and supporting documentation needed for coverage.
Updated contraindication in Criteria I.G.4. regarding intrauterine device for clarity and removed contraindication of recent pregnancy in Criteria I.G.7.
Added requirement that thyroid disorders have been treated or ruled out (Criterion I.F).
Clarified that policy applies to non‑Medicare health plans and added cross‑reference to a Medicare‑specific policy MC.CP.MP.106.
Coverage Criteria for Endometrial Ablation
Initial Therapy
Covered when ALL of the following are met:
See I.A.1 and I.A.2
See I.B and I.C
See I.D-E-F
See I.G.1-I.G.7
Insufficient Evidence / Experimental
Not supported / insufficient evidence:
See II.A and II.B
Photodynamic endometrial ablation procedures are considered unsupported by sufficient scientific evidence and therefore are not supported by this clinical policy.
When state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Providers should consult the applicable state Medicaid manual for any coverage provisions that apply to this policy.
Endometrial ablation performed for indications other than menorrhagia or the specified abnormal uterine bleeding indications listed in the coverage criteria is considered to have insufficient scientific evidence to support effectiveness and is not supported by this clinical policy.
Coding
| 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. |
Provider Actions and Requirements
Medicare Review Requirement
For Medicare members/enrollees, providers must review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles prior to applying the criteria in this clinical policy to ensure consistency with Medicare coverage rules.
Conservative Therapy Requirement
Endometrial ablation is indicated for menorrhagia only after failure of conservative (hormonal or medical) therapy unless such therapy is contraindicated. Documentation that conservative therapy was attempted and was ineffective, or that it is contraindicated, must be provided.
Required Pre-procedure Documentation
Providers must document required pre-procedure findings prior to authorization and perform appropriate testing to exclude significant cervical disease and endometrial malignancy or hyperplasia.
- Document indication per policy Criterion I.A (eg, menorrhagia unresponsive to therapy or other listed indications)
- Provide results of cervical cytology or HPV testing and gynecologic exam that exclude significant cervical disease
- Provide endometrial sampling results that exclude malignancy or hyperplasia
Denial Risk for Missing Required Documentation
Failure to document a required indication or to demonstrate exclusion of malignancy/hyperplasia or significant cervical disease may result in denial of the request for endometrial ablation.
- Missing documentation of prior conservative therapy when required
- Missing cervical cytology/HPV or gynecologic exam results
- Missing endometrial sampling to exclude malignancy/hyperplasia
Providers are expected to exercise professional medical judgment and are responsible for medical advice and treatment. Coverage and payment are subject to the member's benefit plan, applicable state Medicaid provisions (which take precedence if in conflict), and other Health Plan policies and procedures.
- State Medicaid coverage provisions take precedence over this policy if there is a conflict
Background
Endometrial ablation is a minimally invasive procedure intended to treat premenopausal abnormal uterine bleeding in patients who do not desire future fertility. It offers an alternative to hysterectomy for reducing menstrual blood loss, but carries risks including possible treatment failure requiring hysterectomy, infection, uterine perforation, and the potential for pregnancy after ablation.
Both levonorgestrel intrauterine devices and endometrial ablation reduce menstrual blood loss; ablation may be considered when medical or hormonal therapy is ineffective or contraindicated, and it may be used in transgender men with residual menstrual bleeding who do not desire fertility.
Providers should recognize that ablation techniques include a range of first‑generation resectoscopic and second‑generation nonresectoscopic methods, and patient selection must follow the policy's specified indications, preprocedure evaluation, anatomic considerations, and contraindications.
Definitions
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