CurrentCentenePolicy MC.CP.MP.106

Endometrial Ablation

Medicare health plans affiliated with Centene Corporation — medical necessity criteria for endometrial ablation using an FDA-approved device for premenopausal abnormal uterine bleeding and related indications; includes exclusions, contraindications, unsupported uses, and coding guidance.

Policy Summary

PayerCentene

PolicyEndometrial Ablation

Policy CodePolicy MC.CP.MP.106

Change TypeRevisions to criteria, contraindications, and description

Effective Date

Next Review Date

Key ActionPrior to ablation, document cervical cytology or HPV testing and gynecological exam excluding significant cervical disease, and endometrial sampling excluding malignancy or hyperplasia.

SourceLink

POLICY UPDATE CHANGES

Updated description to note absence of coverage criteria from CMS and added sourcing and risk/benefit information.

Updated contraindication regarding intrauterine device for clarity; removed contraindication for recent pregnancy previously listed then reinstated/adjusted across revisions.

Removed phrase 'greater than 3 cm in diameter' from Criteria I.D.

Updated criteria I.A.1. by removing 'at least three months of' (earlier revision) and later clarified androgen therapy threshold for transgender patients to 'at least six months'.

3Primary CPT codes listed

7Contraindications listed

2Unsupported procedure categories

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7Supporting ICD-10 diagnosis codes

Coverage Summary

This policy applies to Medicare health plans affiliated with Centene Corporation and defines medical necessity criteria for endometrial ablation using an FDA‑approved device for treatment of premenopausal abnormal uterine bleeding and related indications. It is intended for patients who generally do not desire future fertility (including specified guidance for transgender patients after at least six months of androgen therapy when applicable). Key safety and risk considerations include infection, bleeding, uterine perforation, fluid volume overload, burns to adjacent tissues, and the possibility of rare but serious pregnancy complications if pregnancy occurs after ablation.

Surface thresholds and quick facts

Policy numberMC.CP.MP.106

StatusCURRENT

Date of last review12/25 (Date of Last Revision: 12/25 / last_review: 2025-12-25)

Androgen therapy duration for transgender patients (threshold)At least six months of androgen therapy

Primary CPT codes listed (count)3 (58353, 58356, 58563)

Contraindications listed (count)7 (Premenopausal with future desire for fertility; Untreated disorders of hemostasis; Pregnancy at time of procedure; Intrauterine device unless removed during procedure; Active pelvic or recent uterine infection; Endometrial hyperplasia or uterine cancer; Post-menopausal)

Unsupported procedure categories (count)2 (Photodynamic endometrial ablation procedures; Endometrial ablation for conditions other than specified indications)

Supporting ICD-10 diagnosis codes (count)7 (N92.0, N92.1, N92.4, N92.5, N92.6, N93.8, N93.9)

Medical-Necessity Criteria

Medically Necessary Criteria

Endometrial ablation using an FDA approved device is medically necessary when ALL of the following are met:

ONE of
- Indication: Menorrhagia unresponsive to hormonal or medical therapy (unless contraindicated to such therapy)
  Document that menorrhagia was unresponsive to hormonal or medical therapy or that such therapy was contraindicated.
- Indication: 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 affirmationAt least six months of androgen therapy

Coding

Primary CPT codes referencedCPT

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)

ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-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

Provider Actions & Billing

Documentation Required

Document pre-procedure evaluations

Prior to ablation, document cervical cytology or HPV testing and gynecological exam excluding significant cervical disease, and endometrial sampling excluding malignancy or hyperplasia.

Documentation Required

Document prior therapies for menorrhagia

Document that menorrhagia was unresponsive to hormonal or medical therapy or that such therapy was contraindicated.

Documentation Required

Document contraception counseling

Document counseling that the patient has no desire for future fertility and has been counseled on required post-procedure contraception.

Background & Definitions

Endometrial ablation is a minimally invasive procedure that destroys the endometrial lining to reduce menstrual bleeding and treat premenopausal abnormal uterine bleeding in patients who do not desire future fertility. It can be an alternative to hysterectomy and is used for menorrhagia unresponsive to medical or hormonal therapy and for residual menstrual bleeding in transgender men who meet specified criteria.

The policy references guidance from the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) to define appropriate candidate selection and risks. Documented risks include infection, bleeding, uterine perforation (reported rates provided for resectoscopic and nonresectoscopic techniques), fluid volume overload, and burns to the vagina, vulva, or bowel. Pregnancy after ablation is rare but possible and can lead to serious fetal and maternal complications; patients should be counseled on required post‑procedure contraception.

Endometrial ablation: Minimally invasive surgical procedures (resectoscopic and nonresectoscopic) to destroy the endometrial lining to reduce menstrual bleeding.

Revision History

12/25revisedLatest

Updated description to note absence of coverage criteria from CMS and added sourcing and risk/benefit information.

09/25revised

Updated contraindication in Criteria I.G.4. regarding intrauterine device for clarity; removed contraindication of recent pregnancy in Criteria I.G.7.; Coding and descriptions reviewed; References reviewed and updated.

09/24revised

Policy Summary

PayerCentene

PolicyEndometrial Ablation

Policy CodePolicy MC.CP.MP.106

Change TypeRevisions to criteria, contraindications, and description

Effective Date

Next Review Date

Key ActionPrior to ablation, document cervical cytology or HPV testing and gynecological exam excluding significant cervical disease, and endometrial sampling excluding malignancy or hyperplasia.

SourceLink

On This Page

Pre-procedure cervical assessment: Cervical cytology or human papillomavirus (HPV) testing and gynecological exam excludes significant cervical disease

Document pre-procedure evaluations.

Endometrial sampling prior to the procedure has excluded malignancy or hyperplasia

Structural anomalies: No structural anomalies, such as fibroids or polyps that require transmural surgery or represent a contraindication to an ablation procedure

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

Thyroid disorders have been treated or ruled out

Contraindications check: Patient does not have any of the listed contraindications (see contraindications node below)

Contraindications (must NOT have any)

Endometrial ablation is not appropriate if any of the following contraindications are present:

Contraindication: Premenopausal with future desire for fertility
Contraindication: Untreated disorders of hemostasis
Contraindication: Pregnancy at time of procedure
Contraindication: Intrauterine device present unless device will be removed during procedure
Contraindication: Active pelvic infection or recent uterine infection
Contraindication: Endometrial hyperplasia or uterine cancer
Contraindication: Post-menopausal status

Not Medically Supported / Insufficient Evidence

Procedures considered unsupported or lacking sufficient evidence:

Unsupported procedure: Photodynamic endometrial ablation procedures (insufficient scientific evidence to support effectiveness)
Unsupported indication: Endometrial ablation for the treatment of all other conditions than those specified in the medically necessary indications

Billing Rule

Use referenced CPT codes for claim submission

Report appropriate CPT codes (58353, 58356, 58563) when submitting claims for endometrial ablation procedures; providers should reference current coding guidance.

58353
58356
58563

Annual review. Updated contraindication in Criteria I.G.4. regarding intrauterine device for clarity; Removed contraindication of recent pregnancy in Criteria I.G.7.; Coding and descriptions reviewed; References reviewed and updated.

02/24revised

Revision logged; Removed phrase 'greater than 3 cm in diameter' from Criteria I.D.; Background updates with no impact to criteria; References reviewed and updated.

08/23revised

Policy developed. Updated criteria under I.A.1. by removing 'at least three months of'; Expanded criteria under I.D. to include fibroids greater than 3cm in diameter; Added additional contraindications including active pelvic infection, endometrial hyperplasia or uterine cancer, recent pregnancy, and post-menopausal; References reviewed and updated.

Multiple (08/23, 02/24, 12/25)revised

Updated criteria I.A.1. by removing 'at least three months of' and later clarified androgen therapy threshold for transgender patients to 'at least six months'.