ModifiedCignaPolicy 0013

Endometrial Ablation (EA) — Coverage Policy

This policy governs coverage and clinical guidance for endometrial ablation techniques as an alternative to hysterectomy for treatment of menorrhagia or excessive anovulatory bleeding, including use for residual bleeding in transgender male patients receiving androgen therapy; it applies to services administered under Cigna health benefit plans.

Policy Summary

PayerCigna

PolicyEndometrial Ablation (EA) — Coverage Policy

Policy CodePolicy 0013

Change TypeAnnual review — revised policy statements

Effective Date

Next Review DateFeb 15, 2025

Key ActionObtain prior authorization and document failed or contraindicated medical therapy, diagnostic sampling to exclude malignancy, and uterine size within device limits before performing endometrial ablation.

SourceLink

POLICY UPDATE CHANGES

Revised policy statement for endometrial ablation for the treatment of menorrhagia or excessive anovulatory bleeding.

Revised the policy statement for endometrial ablation for any other indication.

660participants in key RCT

3CPTs covered when criteria met

12Not covered ICD-10 codes

10-12uterine size limit (cm)

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Coverage Criteria

Medically Necessary (General)

Covered when ALL of the following are met:

EA medical necessity criteria: 1) Diagnosis of menorrhagia or excessive anovulatory bleeding; 2) Patient has failed, is intolerant of, or has contraindication to medical or hormonal treatments (typically tried for at least three months); 3) Diagnostic evaluation (endometrial sampling/biopsy and imaging or hysteroscopy) has excluded endometrial hyperplasia or malignancy and remediable intracavitary pathology; 4) Patient does not desire future fertility; 5) Uterine size/cavity within device limitations (generally ≤10–12 cm in uterine length).uterine length generally ≤ 10-12 cm

EA is also considered medically necessary for residual menstrual bleeding after androgen treatment in an individual with confirmed gender dysphoria undergoing female-to-male hormonal therapy (see policy).

Covered when criteria met (Endometrial ablation for menorrhagia/AUB)

Considered medically necessary when ALL of the following are met:

Primary coverage criteria: 1) Patient has menorrhagia or abnormal uterine bleeding for which endometrial ablation is an accepted therapy; 2) Significant uterine pathology and medical conditions that can cause menorrhagia have been excluded; 3) Medical management has failed, is contraindicated, or is not tolerated; 4) Patient does not desire future fertility and endometrial or uterine cancer has been reliably ruled out.

Based on professional society guidance (ACOG, ASRM, SGS) and applicable policy statements.

Unproven / Not Covered Indications

Experimental/Unproven techniques: Photodynamic endometrial ablation and chemoablation of the endometrium are considered experimental, investigational, or unproven and are not covered due to limited evidence.

Endometrial ablation is not indicated for patients who wish to preserve fertility; candidates must have a clear determination that future childbearing is not desired prior to the procedure. The policy requires exclusion of endometrial hyperplasia and malignancy by appropriate diagnostic evaluation (e.g., endometrial sampling and review of histopathology) before proceeding with ablation. Additionally, EA is not recommended in postmenopausal patients and is limited to the indications specified in this policy (treatment of menorrhagia or excessive anovulatory bleeding and residual bleeding after androgen therapy in individuals with confirmed gender dysphoria).

Endometrial ablation is contraindicated and therefore excluded for the following high-level clinical situations: postmenopausal women; women with known or suspected endometrial cancer or endometrial hyperplasia; and premenopausal women who desire future fertility. Procedures performed for diagnoses listed in the Not Covered section (for example, leiomyomas, uterine or cervical polyps, intrauterine synechiae, and other specified noninflammatory uterine disorders) are not reimbursable under this policy.

Photodynamic endometrial ablation and chemoablation of the endometrium are considered experimental, investigational, or unproven due to limited and inadequate evidence. Published randomized trials for chemoablation and limited data for photodynamic techniques have not established safety and efficacy; accordingly these techniques are not covered under this policy.

When an endometrial ablation claim is submitted with an ICD-10 diagnosis listed in the Not Covered section (for example any of the D25.x leiomyoma codes, N84.x polyp codes, N85.6 intrauterine synechiae, N85.8 other specified noninflammatory uterine disorders, or Z30.2 encounter for sterilization), the service is designated not covered or not reimbursable and may be denied. Claims for EA must be billed with covered diagnosis codes consistent with the policy criteria to avoid denial.

Coding and Billing

Covered/Referenced Codesmixed

No codes listed

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 (e.g., endometrial resection, electrosurgical ablation, thermoablation)

Experimental/Investigational/Unproven CPT CodesCPTExperimental

58579	Unlisted hysteroscopy procedure, uterus.
58999	Unlisted procedure, female genital system (nonobstetrical)

Not Covered ICD-10 CodesICD-10Not Covered

D25.0	Submucous leiomyoma of uterus.
D25.1	Intramural leiomyoma of uterus.
D25.9	Leiomyoma of uterus, unspecified.
N84.0	Polyp of corpus uteri.
N84.1	Polyp of cervix uteri.
N85.6	Intrauterine synechiae.
N85.8	Other specified noninflammatory disorders of uterus.
N92.5	Other specified irregular menstruation.
N94.6	Dysmenorrhea, unspecified.
R93.89	Abnormal findings on diagnostic imaging of other specified body structures.

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Uterine size / device limit

Device uterine length limitUterine length generally ≤ 10–12 cm (uterine size < ~12 weeks' gestation).

Alternate size metricUterine length <13 cm and anterior–posterior width <7 cm (criteria cited for <12 weeks' gestation).

Regulatory noteEA devices have not been approved for use in women with uterine lengths >10–12 cm due to increased risk of uterine or endocervical canal injury.

Selection implicationPatient uterine measurements must be documented and within device limits prior to procedure/authorization.

Clinical correlateUterine size criteria are part of patient selection alongside exclusion of malignancy and completion of childbearing.

Provider Actions and Requirements

Denial Risk

Coding/Claims Denial Risk

Claims submitted without covered procedure or diagnosis codes listed in this policy will be denied as not covered. When billing, providers must use the most appropriate codes as of the date of service.

Affected CPTs: 58353, 58356, 58563 (see prior authorization block)

Denial Risk

Not Covered Diagnosis Triggers Denial

Endometrial ablation is not covered or reimbursable for diagnoses listed in the 'Not Covered or Reimbursable' section. Procedures billed with these ICD-10-CM diagnoses will be denied.

Not covered ICD-10-CM examples: D25.0, D25.1, D25.9, N84.0, N84.1, N85.6, N85.8, N92.5, N94.6, R93.89, Z30.2

Background

Menorrhagia, or heavy menstrual bleeding, is prolonged or excessive uterine bleeding that occurs at regular intervals and is a common cause of gynecologic morbidity, affecting about 20% of women annually. Causes include idiopathic or anovulatory bleeding, systemic disorders (e.g., coagulopathy), and structural uterine pathology. First-line management is conservative medical therapy (NSAIDs, antifibrinolytics, progestins, combined hormonal contraceptives); endometrial ablation is an established minimally invasive alternative to hysterectomy for patients who have failed, are intolerant of, or have contraindications to medical management and who do not desire future fertility. EA techniques include resectoscopic (first-generation) and nonresectoscopic/global (second-generation) methods; device selection and candidacy depend on uterine cavity size and exclusion of malignancy.

Definitions

Menorrhagia / Heavy menstrual bleeding (HMB) definition

Volume-based definitionMenorrhagia (HMB) is more strictly defined as blood loss of ≥80 milliliters per menstrual cycle.

Duration-based definitionAlternatively defined as menstrual bleeding that lasts for more than 7 days.

Clinical impactLeft untreated, menorrhagia can cause anemia, pain, hospitalization, transfusion, and reduced quality of life.

PrevalenceAffects approximately 20% of women each year.

Management noteConservative medical treatments (NSAIDs, antifibrinolytics, progestins, oral contraceptives) are first-line; EA considered when medical therapy fails or fertility is not desired.

Endometrial ablation (EA) — procedural definition

Revision History

2025-02-15annual_reviewLatest

Revised policy statement for endometrial ablation for the treatment of menorrhagia or excessive anovulatory bleeding.

2024-02-15annual_review

Revised the policy statement for endometrial ablation for any other indication.