CurrentFidelis CarePolicy FC.PP.010

Endometrial Ablation Payment Policy

Defines Fidelis Care payment and coverage guidance for endometrial ablation procedures using FDA-approved devices and lists covered CPT and ICD-10-CM codes; applies to all Fidelis Care product types and providers submitting claims.

Policy Summary

PayerFidelis Care

PolicyEndometrial Ablation Payment Policy

Policy CodePolicy FC.PP.010

Change TypeNo material changes

Effective Date

Next Review DateOct 1, 2025

Key ActionProviders should reference current CPT guidance prior to claim submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes listed as covered

7ICD-10-CM diagnosis codes listed as covered

1Photodynamic endometrial ablation not covered

ALLProduct types

Coverage Criteria for Endometrial Ablation

Coverage criteria for endometrial ablation

Covered when ALL of the following are met:

Endometrial ablation is performed using an FDA-approved device.

The procedure is performed for one of the diagnosis codes listed in Table 2 (see ICD-10-CM diagnosis codes considered covered).

Providers bill using the CPT codes listed in Table 1 and reference current CPT guidance prior to claim submission.

The request is not for a photodynamic endometrial ablation procedure.

The procedure is not being performed for a condition other than those listed in Table 2.

Policy Summary

PayerFidelis Care

PolicyEndometrial Ablation Payment Policy

Policy CodePolicy FC.PP.010

Change TypeNo material changes

Effective Date

Next Review DateOct 1, 2025

Key ActionProviders should reference current CPT guidance prior to claim submission.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered CPT and ICD-10-CM Codes

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)

Covered ICD-10-CM 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

Coverage and Coding Guidance / Provider Actions

Billing Rule

Coverage and Coding Guidance

Covered when using an FDA‑approved device for the diagnoses listed in Table 2. Photodynamic endometrial ablation is not covered. Coverage is limited to the CPT codes listed below; inclusion or exclusion of codes does not guarantee coverage and providers should verify coding and coverage before claim submission.

Prior authorization: Follow applicable plan rules if prior authorization is required by the member’s benefit — check member-specific eligibility and benefit systems.
Documentation: Include clinical indication, prior conservative treatments attempted (if applicable), device used (must be FDA‑approved), and operative report supporting use of listed CPT code.
Not covered: Photodynamic endometrial ablation procedures — do not bill Fidelis for these services as covered.
Coding: Use only the appropriate CPT codes when reporting endometrial ablation: 58353, 58356, 58563. Verify modifiers and hysteroscopic guidance descriptors per current CPT guidance.
Medicaid/Medicare note: State Medicaid coverage or Medicare NCD/LCDs supersede this policy where applicable; review state Medicaid manuals and CMS/NCD/LCD guidance prior to billing.

Definitions

Health Plan

DefinitionFor this payment policy, 'Health Plan' means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or affiliates.

ScopeApplies to Fidelis Care product types and providers submitting claims under this payment policy.

AuthorityThis payment policy is the property of Centene Corporation; Fidelis Care may change, amend, or withdraw it at any time.

LimitationThis payment policy does not constitute medical advice, treatment guidance, or guarantee payment; providers retain professional judgment.

Regulatory precedenceState Medicaid provisions and applicable Medicare NCDs/LCDs take precedence where they conflict with this payment policy.