CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Endometrial Ablation Coverage Criteria

Policy governing the medical coverage of endometrial ablation procedures for treatment of abnormal uterine bleeding (menorrhagia) in adult women, including hysteroscopic and nonhysteroscopic techniques.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyEndometrial Ablation Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2015

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility with the member's subscriber agreement or employer agreement before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Covered CPT procedure codes listed

ICD-10 rangeCovered diagnosis codes

2015Effective year shown

2023-02-15Policy last updated

Coverage Criteria for Endometrial Ablation

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Primary coverage criteria: Patient is a woman with abnormal uterine bleeding (menorrhagia)

Primary coverage criteria: Patient is not a candidate for or is unresponsive to hormone therapy

Endometrial ablation is typically preceded by hormonal treatment to thin the endometrium; considered when hormone therapy has failed or is not appropriate.

Primary coverage criteria: Patient would otherwise be considered a candidate for hysterectomy

Procedure is a less invasive alternative to hysterectomy and intended for those who would be candidates for hysterectomy.

Device and technique requirement: Procedure uses a U.S. Food and Drug Administration (FDA)-approved device

Applies to hysteroscopic and nonhysteroscopic techniques; FDA approvals restrict use to women who have completed childbearing.

Applicable Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

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

Covered ICD-10 CodesICD-10Covered

N92.0-N92.64	Excessive, frequent and irregular menstruation codes range (menorrhagia and related)
N93.8	Other specified abnormal uterine and vaginal bleeding
N93.9	Abnormal uterine and vaginal bleeding, unspecified

Provider Actions and Administrative Notes

Prior Authorization

Prior authorization is not required for endometrial ablation under this policy. Providers should nevertheless verify member-specific benefits and eligibility prior to scheduling services because prior authorization requirements can vary by contract and the policy statement does not guarantee coverage.

Verify member benefits and eligibility with BCBSRI prior to service.
Prior authorization: Not applicable (verify contract-specific rules).

Note

Treatment Pathway Context

Endometrial ablation (with or without hysteroscopic guidance, using an FDA‑approved device) may be considered medically necessary for women with abnormal uterine bleeding who are not candidates for, or who are unresponsive to, hormone therapy and who would otherwise be candidates for hysterectomy. Techniques include hysteroscopic and nonhysteroscopic methods; device choice and clinical pathway should follow accepted clinical guidelines and documentation of prior therapies and candidacy for hysterectomy.

Indication: Abnormal uterine bleeding refractory to or intolerant of hormone therapy.
Patient selection: Women who do not desire future fertility (FDA restrictions require completion of childbearing).
Document prior conservative therapy and rationale for ablation vs hysterectomy.

Background

Endometrial ablation involves destruction or removal of the endometrium to treat menorrhagia and is considered a less invasive alternative to hysterectomy. Multiple energy sources and techniques exist, broadly classified as hysteroscopic (first-generation) and nonhysteroscopic (second-generation) methods. Hysteroscopic techniques (for example, Nd-YAG laser, electrosurgical rollerball, transcervical resection) generally require cervical dilation, anesthesia, and fluid distention media, while nonhysteroscopic techniques (for example, thermal balloon, cryoablation, radiofrequency) can often be performed without general anesthesia. Due to risks with future pregnancy, FDA approvals limit use to women who have completed childbearing.

Definitions: Techniques

Hysteroscopic techniques — examples and notes

DefinitionProcedures performed with hysteroscopic guidance that typically require cervical dilation, anesthesia, and fluid distention media.

ExamplesNd-YAG laser; electrosurgical rollerball; transcervical resection (resectoscopic endometrial resection); hydrothermal ablation.

Clinical notesDeveloped as first-generation or resectoscopic techniques and require skilled surgeons due to use of distention media and anesthesia.

Nonhysteroscopic techniques — examples and notes

DefinitionProcedures performed without hysteroscopic guidance or fluid distention media; often can be done without general anesthesia.

ExamplesThermal fluid-filled balloon; cryoablation (cryosurgical endometrial ablation); radiofrequency (RF) ablation; instillation of heated saline.

Clinical notesReferred to as second-generation or nonresectoscopic techniques; avoid risks related to distention media and may be simpler to perform.