CurrentCapital BluecrossPolicy MP 7.013

ENDOMETRIAL ABLATION

Medical policy governing use of FDA‑approved endometrial ablation devices in premenopausal members with abnormal uterine bleeding who have failed, are not candidates for, or decline hormonal therapy, and who would otherwise be candidates for hysterectomy.

Policy Summary

PayerCapital Bluecross

PolicyENDOMETRIAL ABLATION

Policy CodePolicy MP 7.013

Change TypeConsensus and administrative updates

Effective Date11/1/2025

Next Review Date

Key ActionVerify current coding and prior authorization requirements (including HCPCS C1886) and confirm member meets coverage criteria before scheduling procedure.

SourceLink

POLICY UPDATE CHANGES

Not medically necessary language updated to investigational; ACOG recommendations included to Policy Guidelines.

Removed Benefit Variations Section.

Added clarification for coverage of ablation for transgender men and non-binary members.

Changed ablation for postmenopausal members from investigational to not medically necessary (later reversed in 07/16/2025).

MP 7.013policy identifier

Includes ACOGGuideline sources referenced

24%+reported hysterectomy rate

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device/technique categories

~2007-2025reference span

Coverage Criteria

inv-01: Initial therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Primary coverage criteria: Member is premenopausal with abnormal uterine bleeding AND is not a candidate for, is unresponsive to, or declines hormone therapy AND would otherwise be considered a candidate for hysterectomy.

Use of an FDA-approved device is required; patient must have completed childbearing per device labeling.

inv-02: Policy stance and history — policy history indicates coverage determinations and contraindications were placed into policy statements on earlier reviews

Policy history indicates coverage determinations and contraindications were placed into policy statements on earlier reviews.

Policy history and stance: Policy MP 7.013 has undergone multiple reviews; notable items include adding coverage clarification for transgender men and non-binary members, moving postmenopausal ablation between investigational and not medically necessary (and back to investigational), addition of HCPCS code C1886 and deletion of duplicate diagnosis codes, and inclusion of ACOG recommendations into Policy Guidelines.

See policy history entries for dates and details; exact current medical necessity statements are in the policy body.

Endometrial ablation is contraindicated in members who are pregnant or who desire pregnancy. Other absolute exclusions include a history of endometrial cancer or precancerous histology, an active genital or urinary tract infection or active pelvic inflammatory disease at the time of the procedure, and the presence of an intrauterine device (IUD) in situ. Structural or anatomic conditions that interfere with device access or create myometrial weakness (for example, prior classical cesarean section or transmural myomectomy) are also contraindications. Procedures that would exceed the device-specific endometrial cavity size limits are excluded. For microwave ablation specifically, additional contraindications include myometrial thickness < 10 mm and uterine sounding length < 6 cm.

The policy administrative history records an 09/23/2025 administrative update that removed the Benefit Variations section from the document. Prior benefit-variation details and plan-specific exclusions referenced in earlier versions are therefore not present in this excerpt; providers should consult specific plan benefit documents for any program-level differences.

Endometrial ablation is identified in this policy as investigational and not supported for other indications outside the covered population, specifically including postmenopausal bleeding, due to insufficient evidence to conclude that the procedure improves health outcomes for those indications.

Policy history documents that coverage classification for ablation in postmenopausal members has changed over time. Earlier entries note that postmenopausal members were added to the investigational statement (03/23/2021) and later classified as not medically necessary (02/28/2022); a subsequent consensus review (07/16/2025) revised the language to return to investigational. These historical changes may affect prior authorizations and reviews for members falling into the postmenopausal category.

Coding

Covered CPT/HCPCS CodesCPT | HCPCS | mixedCovered

58353	Endometrial ablation, resectoscopic
58356	Ablation of endometrium (nonresectoscopic) — listed as associated
58563	Hysteroscopy, surgical; with endometrial ablation (e.g., global) — listed as associated
C1886	Surgical instrument or device code (listed as associated)

Covered Diagnosis CodesICD-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

Referenced HCPCSHCPCS

C1886

HCPCS code added historically (document lists addition of HCPCS C1886)

Deleted Diagnosis Codes (historical)ICD-10

N93.0	Diagnosis code N93.0 (abnormal uterine and vaginal bleeding) — stated as duplicate and deleted historically
N95.0	Diagnosis code N95.0 (postmenopausal bleeding) — deleted historically

SourceUpToDate (Sharp HT) literature review

CurrencyLiterature review current through Jun 2025

LocationUpToDate Online Journal; updated Sep 06, 2024

UseReferenced to support guideline and evidence summaries within the policy

Provider Actions and Operational Notes

Prior Authorization

Benefit / Product Applicability

Policy applies to Capital Blue Cross commercial and Medicare Advantage products unless a specific product's benefit documents state otherwise. Providers must verify member eligibility and benefit coverage prior to scheduling; benefit variations (including prior authorization requirements and network restrictions) may exist across employer groups and plan types.

Refer to the member's plan-specific evidence of coverage or benefits booklet for coverage determinations and any applicable exclusions or rider limitations.
If benefit variations were previously documented in a removed "Benefit Variations" section, providers must use real-time eligibility and benefits systems or call provider services to confirm applicability.

Billing Rule

Verify Current Coding for Prior Authorization

Prior authorization requirements and code sets may change over time. Providers should verify current CPT/HCPCS and diagnosis codes required for authorization and ensure documentation matches the codes submitted.

Background

Endometrial ablation is a less invasive alternative to hysterectomy for premenopausal women with abnormal uterine bleeding who have completed childbearing and have failed, are not candidates for, or decline hormone therapy. Techniques include both hysteroscopic (resectoscopic) and nonhysteroscopic (for example, thermal balloon, microwave, electrode array, or cryo) methods; device labeling restricts use to women who have completed childbearing and defines device-specific size and anatomy limitations.

Definitions

TermAdenomyosis

DefinitionBenign invasive growth of the endometrium into the muscular layer of the uterus.

Source sectionV. DEFINITIONS

TermHysterectomy

DefinitionSurgical removal of the uterus.

Source sectionV. DEFINITIONS

Term

Revision History

2025-09-23administrative_update

Removed Benefit Variations section (administrative).

2025-07-16consensus_review

Updated 'not medically necessary' language to 'investigational' and added ACOG recommendations to Policy Guidelines.

2024-01-19administrative_update

Clinical benefit language added (administrative update).

Policy Summary

PayerCapital Bluecross

PolicyENDOMETRIAL ABLATION

Policy CodePolicy MP 7.013

Change TypeConsensus and administrative updates

Effective Date11/1/2025

Next Review Date

Key ActionVerify current coding and prior authorization requirements (including HCPCS C1886) and confirm member meets coverage criteria before scheduling procedure.

SourceLink

On This Page

Historically HCPCS C1886 was added to coding; duplicate diagnosis codes (e.g., N93.0) were removed. Confirm the current required procedure and ICD-10 diagnosis codes for prior authorization.
Ensure operative reports and pathology results support the selected diagnosis code(s) and CPT/HCPCS code(s) at the time of prior authorization and claim submission.

Denial Risk

Procedure Contraindications / Denial Risks

Do not perform or seek coverage for endometrial ablation when any contraindication is present; these conditions are common grounds for authorization denial.

Pregnancy or a desire for future pregnancy.
History of endometrial cancer or precancerous histology (e.g., endometrial hyperplasia).
Active genital or urinary tract infection or active pelvic inflammatory disease at time of procedure.
Intrauterine device (IUD) in place.
Anatomic/pathologic conditions that risk myometrial weakness (e.g., prior classic cesarean or transmural myomectomy).
Endometrial cavity size or uterine anatomy exceeding device-specific limitations.
For microwave ablation specifically: myometrial thickness <10 mm or uterine sounding length <6 cm.

Note

Coverage Stance Changes May Affect Authorization

Coverage stance and operational requirements in this policy have changed in past updates and may be updated again. Such changes can affect whether prior authorizations are approved and which members are eligible.

Policy history shows prior edits (e.g., adding HCPCS C1886, changing postmenopausal language from not medically necessary to investigational, removing a Benefit Variations section).
Before submitting or resubmitting authorizations, confirm you are using the policy version effective on the service date and re-check any prior-authorization criteria that may have changed.

Documentation Required

Pre-procedure Evaluation and Counseling

Counseling, pre-procedure testing, and documentation are required operational steps. Ensure pathology review and patient counseling are completed and documented in the medical record before performing ablation.

Test the endometrium of all candidates and review histopathology prior to the procedure; document results in the chart.
Document counseling of premenopausal patients regarding fertility implications and alternative treatments (including hormone therapy and hysterectomy).
Include device-specific cavity size limitations and reasons why the member is a candidate for ablation instead of alternative therapies in the preauthorization and operative documentation.

DefinitionCondition of not having given birth.

Source sectionV. DEFINITIONS

TermEndometrial ablation

DefinitionProcedure that destroys the lining of the uterus to reduce or stop abnormal uterine bleeding.

Clinical contextPresented in policy background as a less invasive alternative to hysterectomy for women who have completed childbearing.

2024-06-05consensus_review

Consensus review with no changes to policy statement; background information and references updated.

2023-06-29consensus_review

Consensus review with coding and references reviewed; no changes to policy statements.

2022-02-28minor_review

Added clarification for coverage of ablation for transgender men and non-binary members; changed ablation for postmenopausal members from investigational to not medically necessary.

2021-03-23minor_review

Per CAC discussion, added postmenopausal members to investigational statement and documented reasoning in Policy Guidelines.

2021-02-16minor_review

Replaced 'women' with 'members', added 'premenopausal', allowed members to decline hormone therapy, added additional contraindications, moved contraindications into policy statements, added cross-references, added HCPCS C1886 and deleted duplicate diagnosis codes N93.0 and N95.0.

2020-02-18consensus_reviewLatest

Consensus review with coding and references reviewed; no changes to policy statements noted in history.