ModifiedCentenePolicy CP.MP.106

Endometrial Ablation

Medical necessity guidelines for endometrial ablation procedures for non-Medicare Centene-affiliated health plans, including indications, contraindications, and supporting background for clinicians and reviewers.

Policy Summary

PayerCentene

PolicyEndometrial Ablation

Policy CodePolicy CP.MP.106

Change TypeCriteria revised and contraindications added

Effective Date

Next Review Date

Key ActionObtain prior authorization with documentation of indication, supporting diagnostics (cytology/HPV and endometrial sampling), and evidence of prior medical/hormonal therapy or contraindication.

SourceLink

POLICY UPDATE CHANGES

Removed requirement for 'at least three months of' medical therapy from I.A.1.

Expanded then later removed the criterion limiting fibroids to greater than 3 cm in diameter within I.D.; final 09/24 revision removed the '>3 cm' limitation.

Added requirement that thyroid disorders have been treated or ruled out (I.F).

Specified additional contraindications including active pelvic infection, recent uterine infection, endometrial hyperplasia or uterine cancer, recent pregnancy, and post-menopausal status.

Clarified policy applies to non-Medicare health plans and added cross-reference to Medicare-specific policy MC.CP.MP.106.

58353,58356,58563CPT codes referenced

N92.x, N93.xICD-10 diagnosis codes

non-MedicarePlan applicability

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Coverage Criteria

Initial Therapy / Coverage Criteria

Covered when ALL of the following are met:

Overall: All conditions A through G must be satisfied for coverage

I (lead)

A. Indications

A1: Menorrhagia unresponsive to hormonal or medical therapy (unless therapy is contraindicated)
I.A.1
A2: 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
I.A.2

B: Cervical cytology or human papillomavirus (HPV) testing and gynecological exam excludes significant cervical disease

I.B

C: Endometrial sampling prior to the procedure has excluded malignancy or hyperplasia

I.C

D: No structural anomalies (e.g., fibroids or polyps) that require transmural surgery or represent a contraindication to an ablation procedure

I.D

E: If anatomic or pathologic conditions exist that may result in a weakened myometrium, only a resectoscopic endometrial ablation is appropriate

I.E

F: Thyroid disorders have been treated or ruled out

I.F

G Contraindications

G.1: Premenopausal with future desire for fertility
I.G.1
G.2: Untreated disorders of hemostasis
I.G.2
G.3: Pregnancy at time of procedure
I.G.3
G.4: Intrauterine device at time of procedure
I.G.4
G.5:

Coverage stance: Endometrial ablation using an FDA-approved device is medically necessary when the above criteria are met for non-Medicare health plans

I (lead)

Insufficient Evidence

Not supported (insufficient evidence):

Not supported: Photodynamic endometrial ablation procedures and endometrial ablation for conditions other than those specified in the covered indications have insufficient scientific evidence to support effectiveness

Photodynamic endometrial ablation procedures are considered to have insufficient scientific evidence to support effectiveness and therefore are not supported by this clinical policy.

Endometrial ablation performed for indications other than the covered indications listed in the policy (for example, diagnoses outside those specified under the coverage criteria) likewise has insufficient evidence to support its effectiveness and is not supported.

Coverage determinations are subject to the terms, conditions, exclusions and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy or contract). The Health Plan’s administrative policies, applicable state and federal requirements, and plan-level procedures apply and may affect coverage decisions.

This clinical policy does not replace or supersede the member’s benefit terms; when discrepancies exist between this policy and the member’s coverage documents or applicable law, the coverage documents and legal/regulatory requirements prevail.

Procedures performed when the policy’s specified coverage criteria are not met — including photodynamic endometrial ablation or ablation for unsupported indications — are considered not medically necessary or unsupported by evidence and may be denied.

Requests may be denied when required documentation supporting medical necessity is absent (for example, absence of indications described in the criteria, or performance of an ablation for conditions explicitly identified as having insufficient evidence).

This clinical policy is a guide to medical necessity and is not a substitute for individual clinical judgment. It does not constitute medical advice, direct the practice of medicine, or guarantee payment for services.

Providers are expected to exercise professional judgment in the care of members/enrollees; the policy is intended to assist in coverage determinations and benefit administration, not to dictate treatment decisions.

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 (eg, endometrial resection, electrosurgical ablation, thermoablation).

Diagnosis Codes that Support Coverage CriteriaICD-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.

Provider Actions / Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for endometrial ablation. Providers must submit the indication for the procedure, relevant diagnostic test results (e.g., cervical cytology/HPV testing, endometrial sampling), and documentation of prior medical or hormonal therapy failure or a documented contraindication to such therapy when applicable.

Submit supporting documentation: cervical cytology or HPV test results, endometrial sampling/pathology report, records of prior medical/hormonal therapy and response, and any relevant imaging or operative notes.

Note

Coverage Conditional on Benefit Terms

Coverage for endometrial ablation is conditional on the member's benefit terms and applicable federal/state laws. Approval under this policy does not guarantee payment — claims remain subject to the terms, exclusions, and limitations of the member's evidence of coverage, certificate, or contract.

Verify member eligibility and benefits prior to scheduling.
Medicaid members: state Medicaid provisions take precedence when they conflict with this clinical policy.

Background

Endometrial ablation is a minimally invasive procedure that targets and destroys the endometrial surface of the uterine cavity using various energy-based techniques. It is used to reduce menstrual bleeding in premenopausal patients who do not desire future fertility and includes first‑generation resectoscopic and second‑generation nonresectoscopic methods. Applicable clinical considerations in the policy include appropriate indications (e.g., menorrhagia unresponsive to medical therapy), preprocedural exclusion of malignancy or significant cervical disease, assessment of structural anomalies, and recognition of contraindications such as desire for future fertility, pregnancy, active pelvic infection, endometrial hyperplasia or uterine cancer, and post‑menopausal status.

Definitions

Endometrial ablation — definition and clinical context

DefinitionTargeted destruction of the endometrial surface of the uterine cavity using various energy sources to reduce menstrual bleeding; preserves the uterus but is contraindicated for patients who desire future fertility.

Primary purposeMinimally invasive treatment for premenopausal abnormal uterine bleeding (menorrhagia) to reduce bleeding and potentially achieve amenorrhea.

Techniques includedFirst-generation (resectoscopic) and second-generation (nonresectoscopic) endometrial ablation methods.

Patient populationsAppropriate for patients who do not desire future fertility; may be considered for transgender men with persistent bleeding after androgen therapy who decline hysterectomy.

Comparative roleAn alternative to more invasive hysterectomy when medication or intrauterine device therapy is ineffective or not desired.