Modifiedpriority healthPolicy 91575-R4

Menorrhagia Treatment

Defines medical necessity, coverage, and coding for treatment options for menorrhagia (heavy menstrual bleeding) including medical therapy, endometrial ablation, dilation and curettage, and hysterectomy; applies to Priority Health members and provider billing.

Policy Summary

Payerpriority health

PolicyMenorrhagia Treatment

Policy CodePolicy 91575-R4

Change TypeModified — material and non-material updates (hysterectomy addedIUD contraception text removedstructural sections added)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionWhen prior authorization is required, submit documentation demonstrating medical necessity including symptomatic menorrhagia measures, negative cervical cytology, and completion of childbearing.

SourceLink

POLICY UPDATE CHANGES

Hysterectomy is medically necessary for the treatment of menorrhagia.

New sections added: Government/Regulations, Guidelines/Position Statements, and FDA/Regulatory.

Coverage-specific information for IUD for contraception was deleted as outside the scope of this policy.

Exclusion for ELITT was deleted.

3+Medically necessary treatments listed

4 groupsProcedure/device code groups

4 codesICD-10 codes highlighted

≥1 device

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Coverage and Medical Necessity Criteria

Endometrial ablation (medical necessity)

Endometrial ablation is considered medically indicated when ALL of the following are present:

Primary symptomatic criteria: Symptomatic menorrhagia (blood loss >80 mL per cycle, bleeding for >8 days, blood loss sufficient to cause anemia or symptoms that significantly interfere with normal activities)>80 mL per cycle; >8 days

Document severity of bleeding and functional impact

Rule out anatomic/pathologic causes: Underlying anatomic or pathologic medical conditions have been ruled out (e.g., active infectious process or pelvic inflammatory disease, uterine polyps or other surgically correctable source of bleeding)

Treatable structural causes should be addressed prior to ablation

Cervical cytology and malignancy exclusion: Cervical cytology is negative and endometrial cancer or precancer is not present

Obtain appropriate evaluation to exclude malignancy per standard of care

Adnexal pathology exclusion: Adnexal tumors are not present

Imaging or clinical evaluation as indicated

Completion of childbearing: Desire for childbearing completed

Ablation is intended for those who do not desire future fertility

Device and labeling: The device utilized for endometrial ablation must be an FDA approved device and used as labeled

Follow manufacturer labeling and FDA-approved indications

Other medically necessary treatments

Other listed medically necessary treatments (no additional criteria provided in this part of the document):

Medical therapy: Hormonal therapy including levonorgestrel-releasing intrauterine systems (e.g., Mirena) or other pharmacotherapy as determined by member's specific plan

Refer to member benefit documents for contraceptive use

Hysterectomy is medically necessary for the treatment of menorrhagia

Considered when nonsurgical therapies fail or are contraindicated and childbearing is complete

Dilation and curettage

May be used as indicated for diagnostic or therapeutic purposes

Coverage-specific language addressing use of intrauterine devices (IUDs) for contraception has been removed from this menorrhagia policy and is now governed by member benefit documents and the Priority Health Provider Manual. Affected codes referenced in the original text include J7296, J7300, and J7301 (contraception-only codes); the policy also lists device-related codes J7297, J7298, 58300 (IUD insertion), and 58301 (IUD removal) but directs contraceptive use questions to benefit documentation.

None specified in this portion of the document.

An exclusion that specifically referenced ELITT was removed from the policy; there is no remaining ELITT-specific exclusion in the current document.

These portions of the policy do not contain explicit statements labeling any listed services as 'not medically necessary.'

Procedure, Device, and Diagnosis Codes

CPT/HCPCS 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)

IUD and device codesHCPCS | CPTCovered

J7297	Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg
J7298	Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg
58300	Insertion of intrauterine device (IUD)
58301	Removal of intrauterine device (IUD)

ICD-10 CodesICD-10

N80.0	Endometriosis of uterus
N85.9	Noninflammatory disorder of uterus, unspecified
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
N92.6	Irregular menstruation, unspecified
N93.8	Other specified abnormal uterine and vaginal bleeding
N93.9	Abnormal uterine and vaginal bleeding, unspecified

CPT copyright noticemixed

CPT	All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association.

Menstrual blood loss threshold

Menstrual blood loss threshold>80 mL per cycle

Source contextSymptomatic menorrhagia defined in policy criteria

Use in documentationRequired to demonstrate medical necessity for endometrial ablation

Duration threshold

Duration threshold>8 days

Source contextBleeding duration criterion for symptomatic menorrhagia

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain drugs, services, and procedures. When prior authorization is required, the provider must submit a request demonstrating that the drug, service, or procedure is medically necessary. Failure to obtain required prior authorization may result in denial of payment.

Providers should verify prior authorization requirements with Priority Health before scheduling services.
Refer to the Priority Health Provider Manual for prior authorization procedures and submission details.

Prior Authorization

Prior Authorization Guidance

This policy does not list every CPT/HCPCS code that may require prior authorization. Eligibility and benefit verification is required prior to rendering services to confirm coverage and any plan-specific requirements.

Check the member’s specific plan documents and benefits for applicable limits or exclusions.
Contact Provider Services or use online tools to verify benefit and authorization requirements.

Clinical Background

Abnormal uterine bleeding describes changes in the frequency, duration, or amount of menstrual bleeding; when bleeding is excessive or prolonged it is commonly termed menorrhagia. Management ranges from medical therapy (including hormonal options and levonorgestrel-releasing intrauterine systems) to procedural interventions such as dilation and curettage, endometrial ablation, or hysterectomy when childbearing is complete and nonsurgical options have failed or are contraindicated.

For consideration of endometrial ablation specifically, medical necessity is generally demonstrated by symptomatic menorrhagia — for example, blood loss exceeding 80 mL per cycle, bleeding lasting longer than 8 days, resulting anemia, or bleeding that significantly interferes with daily activities — after anatomic or pathologic causes have been ruled out and cancer or precancer has been excluded.

Key Definitions and Classification

Menorrhagia / Abnormal uterine bleeding

DefinitionChange in the frequency of menses, the duration of flow, or the amount of blood loss; commonly presents as excessive or prolonged bleeding (menorrhagia).

Common presentationExcessive or prolonged menstrual bleeding (menorrhagia)

Clinical relevanceMay be managed with medical therapy, D&C, endometrial ablation, or hysterectomy when childbearing is complete

Medical necessity for endometrial ablation

Primary symptomatic criteriaSymptomatic menorrhagia defined as blood loss >80 mL per cycle, bleeding for >8 days, or blood loss causing anemia or significant interference with activities

Anatomic/pathologic exclusionUnderlying anatomic or pathologic causes (e.g., active infection/PID, uterine polyps, surgically correctable sources) must be ruled out