CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Endometrial ablation for abnormal uterine bleeding

Defines medical necessity coverage for endometrial ablation (hysteroscopic and nonhysteroscopic techniques) for women with abnormal uterine bleeding who have failed or are not candidates for hormone therapy and would otherwise be candidates for hysterectomy; includes applicable CPT and ICD-10 codes and background/evidence summary. Applies to Medicare Advantage and commercial products; benefits may vary by contract.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyEndometrial ablation for abnormal uterine bleeding

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument that the patient is not a candidate for or is unresponsive to hormone therapy and that the patient would otherwise be considered a candidate for hysterectomy before performing endometrial ablation.

POLICY UPDATE CHANGES

No material changes

3CPT codes listed as covered

5ICD-10 diagnosis codes or ranges referenced

1Primary coverage statement

Coverage Summary

Defines medical necessity coverage for endometrial ablation (hysteroscopic and nonhysteroscopic techniques) for women with abnormal uterine bleeding who have failed or are not candidates for hormone therapy and would otherwise be candidates for hysterectomy. Applies to Medicare Advantage and commercial products; benefits may vary by contract. Coverage requires use of a U.S. Food and Drug Administration (FDA)-approved device. See the evidence summary for trial and systematic review findings regarding comparative outcomes.

Medical-Necessity Criteria

Medically Necessary Criteria

Endometrial ablation with an FDA-approved device may be considered medically necessary when ALL of the following are met:

Patient is a woman with abnormal uterine bleeding
Patient is not a candidate for or is unresponsive to hormone therapy
Provider must document that the patient is not a candidate for or is unresponsive to hormone therapy prior to performing endometrial ablation.
Patient would otherwise be considered a candidate for hysterectomy
Provider must document that the patient would otherwise be considered a candidate for hysterectomy.
Procedure performed using a U.S. Food and Drug Administration (FDA)-approved device

Fertility Consideration / Exclusion

Operational limitation / contraindication:

Procedure is not recommended for women who wish to preserve their fertility (FDA approvals include women for whom childbearing is complete)

Provider Actions

Documentation Required

Document failure or contraindication to hormone therapy

Provider must document that the patient is not a candidate for or is unresponsive to hormone therapy prior to performing endometrial ablation.

Documentation Required

Document candidacy for hysterectomy

Provider must document that the patient would otherwise be considered a candidate for hysterectomy.

Billing Rule

Pair CPT with appropriate ICD-10

Endometrial ablation CPT codes should be filed with one of the listed ICD-10 diagnosis codes to be considered medically necessary; these pairings are required for medical necessity determination.

CPT: 58353
CPT: 58356
CPT: 58563
ICD-10: N92.0-N92.6
ICD-10: N93.8
ICD-10: N93.9
Instruction: These CPT–ICD-10 pairings are required for medical necessity determination.

Coding

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 (e.g., endometrial resection, electrosurgical ablation, thermoablation)

Applicable ICD-10 diagnosis codes (covered when filed with above CPT codes)ICD-10Covered

N92.0-N92.6	Excessive and frequent menstruation and related codes (range listed in policy)
N93.8	Other specified abnormal uterine and vaginal bleeding
N93.9	Abnormal uterine and vaginal bleeding, unspecified

Background and Evidence

Endometrial ablation is a less invasive alternative to hysterectomy for abnormal uterine bleeding in women who have failed standard (hormonal) therapy. Techniques include hysteroscopic (first-generation) methods such as Nd-YAG laser, electrosurgical rollerball, and resecting loop, and nonhysteroscopic (second-generation) methods such as thermal fluid-filled balloon, cryosurgical ablation, heated saline instillation, and radiofrequency ablation. FDA approvals for endometrial ablation devices are limited to women for whom childbearing is complete because of pregnancy-related risks after ablation. Compared with medical therapy, endometrial ablation provides reasonable symptom control, and compared with hysterectomy, it is less invasive though hysterectomy offers greater symptom relief and fewer reoperations.

Randomized controlled trials and systematic reviews demonstrate that endometrial ablation results in a meaningful improvement in net health outcome versus medical therapy for abnormal uterine bleeding. However, RCTs and meta-analyses have found that hysterectomy provides greater symptom relief and fewer reoperations than endometrial ablation, while ablation yields reasonable symptom control and the advantage of avoiding a more invasive procedure.

Definitions