CurrentCentenePolicy MC.CP.MP.106

Endometrial Ablation

Medicare clinical policy describing medical necessity criteria for endometrial ablation using FDA-approved devices for premenopausal abnormal uterine bleeding in members/enrollees of Centene-affiliated Medicare health plans.

Policy Summary

PayerCentene

PolicyEndometrial Ablation

Policy CodePolicy MC.CP.MP.106

Change TypeRevised criteria / Added contraindications

Effective Date

Next Review Date

Key ActionDocument cervical cytology or HPV testing and gynecologic exam excluding significant cervical disease, and endometrial sampling excluding malignancy or hyperplasia prior to performing endometrial ablation; also document prior medical/hormonal therapy unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

Updated criteria under I.A.1. by removing 'at least three months of' medical therapy requirement.

Expanded and subsequently removed language about fibroids greater than 3 cm in diameter in Criteria I.D.

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

1Primary indication group (menorrhagia/abnormal uterine bleeding)

7Contraindications listed

3CPT procedure codes explicitly referenced

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Medical Necessity Criteria

Medically Necessary

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

ALL of the following

Indication (one of the following):
- Menorrhagia unresponsive to hormonal or medical therapy (unless contraindicated to such therapy).
- 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.
Cervical cytology or human papillomavirus (HPV) testing and gynecological exam excludes significant cervical disease.
Endometrial sampling prior to the procedure has excluded malignancy or hyperplasia.
No structural anomalies, such as fibroids or polyps, that require transmural surgery or represent a contraindication to an ablation procedure.
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.
Does not have any of the following contraindications:
- Premenopausal with future desire for fertility.
- Untreated disorders of hemostasis.
- Pregnancy at time of procedure.
- Intrauterine device in place at time of procedure.
- Active pelvic infection or recent uterine infection.
- Endometrial hyperplasia or uterine cancer.

Insufficient Evidence / Not Supported

The policy finds insufficient scientific evidence to support effectiveness for:

ANY of the following

Photodynamic endometrial ablation procedures.
Endometrial ablation for the treatment of all other conditions than those specified in the medically necessary criteria.

Relevant Procedure and Diagnosis Codes

Covered / Referenced 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).

ICD-10-CM 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.

What Providers Must Do / Watch For

Documentation Required

Pre-procedure diagnostic documentation

Document cervical cytology or human papillomavirus (HPV) testing and a gynecologic exam that excludes significant cervical disease, and document endometrial sampling prior to the procedure that excludes malignancy or hyperplasia.

Documentation Required

Therapy history

Document that hormonal or other medical therapy for menorrhagia was attempted unless such therapy is contraindicated. Note: the policy removed the prior minimum-duration requirement (no minimum therapy duration is required).

Prior Authorization

Prior authorization expectation

This policy applies to Medicare health plans affiliated with Centene Corporation; follow plan-level prior authorization processes where applicable and review all relevant Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying these criteria.

Clinical and Administrative Background

Endometrial ablation is a minimally invasive surgical option to treat premenopausal abnormal uterine bleeding and heavy menstrual bleeding for patients who do not desire future fertility. It is an alternative to hysterectomy that preserves the uterus while reducing menstrual blood loss and often improving quality of life. Both first‑generation (resectoscopic) and second‑generation (nonresectoscopic) techniques are used, and these different methods have variable rates of amenorrhea and distinct complication profiles.

The procedure includes multiple energy‑based approaches targeting the endometrial surface; choice of technique may influence treatment time, device characteristics, and amenorrhea rates. Although ablation frequently achieves reduced bleeding, it is not universally definitive—some patients may experience persistent bleeding or later require repeat procedures or hysterectomy.

Pregnancy can still occur after endometrial ablation, and there are specific postoperative risks (for example, pregnancy after ablation, pain from obstructed menses, infection, and uterine perforation). Therefore, premenopausal patients should be counseled to use an appropriate method of contraception if future pregnancy is not desired.

Defined Terms

Definitions

Endometrial ablationTargeted destruction of the endometrial surface of the uterine cavity using energy-based devices (resectoscopic or nonresectoscopic techniques) to reduce or stop menstrual bleeding.

MenorrhagiaExcessive menstrual bleeding; policy references medical therapy failure as an indication for ablation.

Policy Changes

08/23revised

Updated criteria under I.A.1. by removing 'at least three months of' medical therapy requirement (simplifying prior duration requirement).

02/24revised

Updated criteria under I.A.1. by removing 'at least three months of' medical therapy requirement; expanded criteria under I.D. to include fibroids greater than 3 cm in diameter and added additional contraindications under I.G.5–I.G.8 (active pelvic or recent uterine infection, endometrial hyperplasia or uterine cancer, recent pregnancy, and post‑menopausal).

09/24revised