CurrentPremera BluecrossPolicy MP-089

Endometrial Ablation

Defines medical necessity criteria, coding, and limitations for endometrial ablation for premenopausal individuals with abnormal uterine bleeding; intended for providers and applies to Premera individual plans.

Policy Summary

PayerPremera Bluecross

PolicyEndometrial Ablation

Policy CodePolicy MP-089

Change TypeMaterial clinical and operational updates

Effective DateApr 1, 2026

Next Review DateMar 23, 2027

Key ActionObtain prior authorization when applicable and document failed conservative therapy, negative cancer testing, and pathology within one year.

SourceLink

POLICY UPDATE CHANGES

Added indication for residual menstrual bleeding resulting from medically necessary gender-affirming androgen therapy.

Limitation noting endometrial ablation is not recommended for adolescent members receiving gender affirming treatment due to higher rate of reoperation.

Background and Regulatory sections removed per criteria updates; minor formatting updates throughout policy.

All of the followingCriteria logic for medical necessity

3Procedure codes listed

3Diagnosis code ranges

1 yrPathology timing

<=3 cmMax myoma size

Coverage Criteria for Endometrial Ablation

COVERAGE CRITERIA

Covered when ALL of the following are met

Primary medical necessity

Diagnosis: Individual is premenopausal with a normal endometrial cavity by ultrasound and has been diagnosed with menorrhagia, or has patient-perceived heavy menstrual bleeding interfering with activities of daily life, or has residual menstrual bleeding resulting from medically necessary gender-affirming androgen therapy.
Fertility and pregnancy status: Individual is not pregnant and has no desire for future fertility.
Cancer exclusion and testing: Negative testing for uterine cancer and endometrial hyperplasia, negative cervical cytology, and endometrial tissue sampling/biopsy demonstrating lack of cancer or endometrial hyperplasia (pathology results performed within one year).

Policy Summary

PayerPremera Bluecross

PolicyEndometrial Ablation

Policy CodePolicy MP-089

Change TypeMaterial clinical and operational updates

Effective DateApr 1, 2026

Next Review DateMar 23, 2027

Key ActionObtain prior authorization when applicable and document failed conservative therapy, negative cancer testing, and pathology within one year.

SourceLink

On This Page

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Coding — CPT and ICD-10

Covered CPT CodesCPTCovered

58353	Endometrial ablation, without hysteroscopic guidance
58356	Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
58563	Hysteroscopy, surgical, with endometrial ablation

ICD-10 Codes Covered if Selection Criteria are MetICD-10Covered

D25.0-D25.9	Leiomyoma of uterus
N92.0-N92.6	Excessive, frequent, and irregular menstruation
N93.0-N93.8	Abnormal uterine and vaginal bleeding

Submucosal myoma diameter — maximum size threshold for coverage

Maximum submucosal myoma diameterLess than 3 cm (coverage limit for menorrhagia associated with submucosal myomata)

Context for thresholdApplies when menorrhagia or excessive bleeding occurs in the setting of submucosal myomata

Implication for eligibilityMyoma diameter ≥3 cm would not meet this specific limitation and may preclude coverage

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed CPT codes where applicable. Submit prior authorization requests before scheduling procedures to confirm coverage.

Prior authorization required for CPT 58353, 58356, 58563

Denial Risk

Triggers for Denial / Not Recommended

Endometrial ablation will be denied when any of the following exclusion conditions are present.

Pregnancy or desire for future fertility
Positive testing for uterine cancer or endometrial hyperplasia
Positive cervical cytology indicating malignancy or pre-malignant disease
Presence of submucosal myomata ≥ 3 cm in diameter (if menorrhagia is due to myomata)
Adolescents receiving gender-affirming treatment (procedure not recommended due to higher reoperation rates)

Documentation Required

Required Documentation

Provide documentation that supports all selection criteria and timing requirements. Include copies of imaging, pathology, prior treatment records, and device information.

Pelvic ultrasound demonstrating a normal endometrial cavity
Negative cervical cytology results (Pap test)
Endometrial tissue sampling/biopsy pathology report showing no cancer or endometrial hyperplasia — pathology must be performed within 1 year of the procedure
Documentation that the device to be used is FDA-approved for endometrial ablation
If submucosal myomata are present and menorrhagia is the indication, include measurement showing diameter < 3 cm

Documentation Required

Failure of Conservative Therapy

Document failure of conservative therapy or a contraindication to same before approval. Conservative therapies include medical and hormonal treatments.

Record of adequate trial and insufficient response to medical therapies (e.g., hormonal treatments, other medications) OR documentation of a contraindication to medical/hormonal therapy
For members on gender-affirming androgen therapy with residual bleeding, document bleeding attributable to therapy and rationale for ablation
Note: Failure of conservative therapy must be clearly described in the medical record and included with the prior authorization request

Definitions

Menorrhagia / Heavy menstrual bleeding — definition and clinical framing

DefinitionExcessive menstrual blood loss that interferes with quality of life; may be patient-reported or diagnosed clinically.

Clinical framing for coverageConsidered when the individual is premenopausal with a normal endometrial cavity by ultrasound and has been diagnosed with menorrhagia or reports heavy menstrual bleeding that interferes with activities of daily life.

Related indicationsAlso includes residual menstrual bleeding resulting from medically necessary gender-affirming androgen therapy (per updated criteria).

Premenopausal — definition used for coverage eligibility

Definition used in policyIndividual who has not completed menopause (premenopausal).

Coverage requirementPremenopausal status is required for endometrial ablation to be considered medically necessary.

Assessment methodPremenopausal status determined clinically as part of evaluation prior to offering ablation (implied by criteria requiring premenopausal individuals).

Background

Endometrial ablation is a minimally invasive procedure that destroys or removes the uterine lining to reduce heavy menstrual bleeding. Multiple energy modalities may be used (for example, cold, electrical, laser, microwave, radiofrequency, or heated fluids), and the procedure is intended for premenopausal individuals who do not desire future fertility. Coverage is limited to cases where there is a normal endometrial cavity on ultrasound and the individual has menorrhagia, patient-perceived heavy menstrual bleeding that interferes with activities of daily life, or residual bleeding from medically necessary gender-affirming androgen therapy. When submucosal myomata are present, eligible lesions must be less than 3 cm in diameter, and pathology results must be current within one year.