Modifiedpartners_health_managementPolicy NC.CP.MP.106

Endometrial Ablation

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Medical necessity guidelines for endometrial ablation for non‑Medicare health plans affiliated with Centene/Partners Health Management, including indications, contraindications, and coding references affecting providers and payers.

Policy Summary

Payerpartners_health_management

PolicyEndometrial Ablation

Policy CodePolicy NC.CP.MP.106

Change TypeMaterial clinical and operational revisions

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document medical necessity including indication, cervical cytology/HPV testing, endometrial sampling results (or note if sampling not possible), and relevant diagnosis codes.

SourceLink

POLICY UPDATE CHANGES

Added note to refer to MC.CP.MP.106 for Medicare criteria and specified 'non‑Medicare' health plans in Policy/Criteria I. and II.

Added requirement that thyroid disorders have been treated or ruled out prior to ablation.

Expanded criteria for structural anomalies to include fibroids (removal of size-based restriction) and updated I.D. wording to 'no structural anomalies that require transmural surgery or represent a contraindication to an ablation procedure.'

Removed prior contraindication: 'previous classical cesarean or other transmural surgery' from contraindications.

I & IIdistinct policy sections

3CPT codes listed

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Modifiedpartners_health_managementPolicy NC.CP.MP.106

Endometrial Ablation

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Policy Summary

Payerpartners_health_management

PolicyEndometrial Ablation

Policy CodePolicy NC.CP.MP.106

Change TypeMaterial clinical and operational revisions

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Added note to refer to MC.CP.MP.106 for Medicare criteria and specified 'non‑Medicare' health plans in Policy/Criteria I. and II.

Added requirement that thyroid disorders have been treated or ruled out prior to ablation.

Removed prior contraindication: 'previous classical cesarean or other transmural surgery' from contraindications.

I & IIdistinct policy sections

3CPT codes listed

Thyroid addedPreprocedure requirement

IncludedMedicaid/Medicare notes

Coverage Criteria for Endometrial Ablation

Initial Therapy / Medical necessity

Covered when ALL of the following are met:

Primary policy criteria

Indications
- Menorrhagia indication: Menorrhagia unresponsive to hormonal or medical therapy (unless such therapy is contraindicated).
- Transgender 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 affirmation.
Preprocedure disease exclusion: Cervical cytology or human papillomavirus (HPV) testing and gynecological exam exclude significant cervical disease.
Endometrial sampling prior to the procedure has excluded malignancy or hyperplasia; or preprocedural sampling is technically not possible.
Structural anatomy: No structural anomalies 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: Member does not have any of the following contraindications: premenopausal with future desire for fertility; untreated disorders of hemostasis; pregnancy at time of procedure; active pelvic infection or recent uterine infection; endometrial hyperplasia or uterine cancer; recent pregnancy; post‑menopausal.

Insufficient scientific evidence

Not supported (insufficient evidence) for the following:

Insufficient Evidence: Photodynamic endometrial ablation procedures; endometrial ablation for treatment of conditions other than those specified in coverage criteria.

Photodynamic endometrial ablation is explicitly listed in the policy as a procedure for which there is insufficient scientific evidence to support effectiveness and therefore is not supported under this coverage policy. The policy groups photodynamic techniques with other uses of endometrial ablation that are outside the specified indications and states these uses are not supported.

The policy references external evidence and guidance in its bibliography; NICE guidance (IPG47) is discussed among referenced national guidance sources. While the policy notes discussion of photodynamic endometrial ablation in NICE IPG47, the excerpted material does not provide an explicit coverage determination from NICE within these document sections.

This policy considers endometrial ablation not medically necessary or insufficiently supported for several patient groups and indications. Specifically, endometrial ablation is not supported for post‑menopausal individuals and is contraindicated for patients who desire future fertility. More broadly, the policy states that ablation for conditions other than the specified indications (for example, indications outside menorrhagia unresponsive to medical therapy or the defined transgender indication) lacks sufficient evidence and is not supported.

Coding References

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 coverageICD-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, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for CPT 58353, 58356, 58563

Prior authorization is expected for endometrial ablation procedures billed with CPT 58353, 58356, or 58563. Authorization requests should include documentation that demonstrates the medical necessity criteria are met (indication, prior therapies, preprocedure evaluation, and relevant diagnostic findings).

CPT 58353 — Endometrial ablation, thermal, without hysteroscopic guidance
CPT 58356 — Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
CPT 58563 — Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)

Prior Authorization

Verify plan, Medicare, and state coverage rules before submission

Verify prior authorization requirements with the member's Health Plan administrative policies and coverage documents. For Medicare members review applicable NCDs/LCDs; for Medicaid members review the state Medicaid manual as state provisions take precedence.

Background and Scope

Endometrial ablation is a minimally invasive surgical procedure intended to destroy or remove the endometrial lining to treat abnormal uterine bleeding in patients who do not desire future fertility. The policy recognizes both resectoscopic (first‑generation) and nonresectoscopic (second‑generation) techniques and indicates ablation is intended primarily for premenopausal individuals with heavy or abnormal menstrual bleeding unresponsive to medical therapy; it may also be considered for people with a female reproductive system receiving gender‑affirming androgen therapy who continue to have problematic uterine bleeding after at least six months of therapy.

Definitions and Technique Classification

inv-17: Endometrial ablation — Definition (minimally invasive procedure; patient considerations)

DefinitionEndometrial ablation is a minimally invasive surgical procedure to destroy or remove the endometrial lining of the uterus to treat premenopausal abnormal uterine bleeding; it preserves the uterus but is indicated for patients who do not desire future fertility.

Patient selectionIntended for premenopausal individuals with abnormal uterine bleeding who have failed or are not candidates for medical/hormonal therapy; may be considered for transgender men with residual menstrual bleeding who do not desire fertility and decline hysterectomy.

Fertility considerationNot appropriate for patients who desire future fertility; counseling regarding permanent impact on fertility is required prior to the procedure.

Minimally invasive natureProcedure is less invasive than hysterectomy and may improve quality of life by reducing menstrual blood loss and achieving amenorrhea in some patients.

Related guidance noteFor Medicare-specific criteria, refer to the related Medicare policy MC.CP.MP.106.

Policy Summary

Payerpartners_health_management

PolicyEndometrial Ablation

Policy CodePolicy NC.CP.MP.106

Change TypeMaterial clinical and operational revisions

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Check Health Plan-level administrative policies and coverage documents before submitting requests
Review Medicare NCDs/LCDs and Medicare Coverage Articles when applicable
Refer to the state Medicaid manual for Medicaid members when state provisions conflict with this policy

Step Therapy

Expect prior medical (including hormonal) therapy for menorrhagia

Medical therapy, including hormonal therapy, is expected as initial treatment; endometrial ablation is indicated for menorrhagia unresponsive to hormonal or medical therapy unless such therapy is contraindicated.

Step Therapy

No step therapy specified

No step therapy requirements are specified in these document excerpts.

Documentation Required

Required clinical and diagnostic documentation for claims

Document the indication (e.g., menorrhagia unresponsive to medical therapy or abnormal uterine bleeding), cervical cytology or HPV testing and gynecologic exam excluding significant cervical disease, endometrial sampling results or reason sampling was not possible, and the relevant diagnosis code(s) when submitting claims.

Record prior medical/hormonal therapy and response
Include cervical cytology or HPV testing and gynecologic exam findings
Include endometrial sampling pathology or documentation if sampling was not technically possible
Append supporting ICD-10 diagnosis code(s) for abnormal uterine bleeding

Documentation Required

Document clinical rationale and adherence to standards of practice

Document the clinical rationale for the procedure and that care follows generally accepted standards of medical practice. Providers are expected to exercise professional judgment and comply with applicable state and federal coverage provisions and Health Plan administrative policies.

Denial Risk

Denial triggers when criteria are unmet

Requests may be denied if coverage criteria are not met. Common denial triggers include post‑menopausal status, desire for future fertility, untreated disorders of hemostasis or thyroid disorders not treated/ruled out, pregnancy or recent pregnancy, active pelvic or recent uterine infection, endometrial hyperplasia or uterine cancer, or structural anomalies that require transmural surgery.

Post‑menopausal status
Premenopausal with future desire for fertility
Untreated disorders of hemostasis
Thyroid disorders not treated or ruled out
Pregnancy at time of procedure or recent pregnancy
Active pelvic infection or recent uterine infection
Endometrial hyperplasia or uterine cancer
Structural anomalies requiring transmural surgery

Note

State Medicaid rules take precedence over this policy

When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid provisions take precedence; refer to the state Medicaid manual for applicable coverage rules.

inv-18: First- and second-generation techniques — Resection vs nonresectoscopic methods

First-generation techniquesResectoscopic (first-generation) techniques involve direct visualization and resection of endometrial tissue using hysteroscopic instrumentation.

Second-generation techniquesNonresectoscopic (second-generation) methods use various global or device-based energy sources (eg, thermal, cryoablation, radiofrequency, balloon, or other technologies) to ablate the endometrium without resectoscopy.

Technique selection considerationsIf anatomic or pathologic conditions may weaken the myometrium, only resectoscopic ablation is appropriate because of specific anatomic considerations outlined in coverage criteria.

inv-19: Abnormal uterine bleeding / heavy menstrual bleeding — Definition and relationship to FIGO classification and cited guidance

Definition (AUB/HMB)Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), refers to clinically significant deviations in menstrual bleeding patterns that may be classified using the FIGO PALM-COEIN system and are the primary indications targeted by endometrial ablation therapies.

FIGO referenceThe policy cites the FIGO classification (PALM-COEIN) as a framework for causes of abnormal uterine bleeding in reproductive-age, nongravid women (Munro et al.).

Guideline and evidence contextEndometrial ablation is supported by evidence and guideline reviews (eg, Cochrane, specialty reviews, FDA guidance) as an effective option to reduce menstrual blood loss for appropriate AUB/HMB patients when selection criteria are met.