Endometrial Ablation
Medical necessity guidelines for endometrial ablation for Medicare health plans affiliated with Centene Corporation, covering indications, contraindications, and coding for providers performing the procedure.
Removed the requirement for 'at least three months of' prior medical therapy from criteria I.A.1.
Expanded and then subsequently removed wording about fibroids greater than 3 cm in diameter in criterion I.D.
Added explicit contraindications including active pelvic infection or recent uterine infection, endometrial hyperplasia or uterine cancer, recent pregnancy, and post-menopausal status under I.G.5-I.G.8.
Coverage Criteria for Endometrial Ablation
Insufficient Evidence / Not Supported
Not supported (insufficient evidence):
These uses are considered unsupported by the available evidence
Photodynamic endometrial ablation is considered not supported because the available scientific evidence is insufficient to demonstrate its effectiveness. The policy explicitly lists photodynamic endometrial ablation procedures among treatments for which there is insufficient scientific evidence to support coverage.
Endometrial ablation performed for indications other than the specific conditions outlined in the medical necessity criteria is considered not supported due to insufficient scientific evidence. The policy states that ablation for any conditions beyond those specified is not supported.
Coding
| 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 and CPT Codes
Prior authorization is required for endometrial ablation. Submit the request with supporting documentation (see items) and include the applicable CPT code(s) on the prior authorization submission.
Prior Medical Therapy
Documented trial of prior medical or hormonal therapy for menorrhagia or abnormal uterine bleeding is expected unless there is a documented contraindication or the clinical scenario makes medical therapy inappropriate.
- Prior medical/hormonal therapy should be clearly described in the record (agent, dose, duration, response).
- Operational change: no minimum three-month duration is required; document that medical therapy was attempted and was ineffective or contraindicated.
- If medical therapy is contraindicated, include the specific contraindication in the record.
Required Pre-procedure Documentation
Required pre-procedure documentation must be provided with the prior authorization request or be present in the medical record at time of audit.
- Indication for procedure (specific diagnosis supporting coverage, e.g., ICD-10: N92.0, N92.1, N92.4, N92.5, N92.6, N93.8, N93.9).
- Cervical cytology and/or HPV testing and documented gynecological exam excluding significant cervical disease.
- Endometrial sampling pathology report excluding malignancy or hyperplasia prior to ablation.
- Documentation of prior medical/hormonal therapy or documented contraindication.
- Assessment excluding structural anomalies that contraindicate ablation (e.g., fibroids or polyps requiring transmural surgery) or note if resectoscopic ablation is chosen for weakened myometrium.
- Pregnancy status and absence of intrauterine device; absence of active pelvic or recent uterine infection. (See contraindications list.)
Denial Triggers
Claims or requests lacking required documentation or with disqualifying findings are subject to denial. Denial will be triggered when any absolute contraindication or missing essential documentation is present.
- Denial triggers include: documented desire for future fertility in premenopausal patients; untreated bleeding disorders; pregnancy; presence of IUD at time of procedure; active or recent uterine/pelvic infection; endometrial hyperplasia or uterine cancer; recent pregnancy; post-menopausal status.
- Lack of documented indication or lack of prior medical/hormonal therapy documentation (or documented contraindication) may result in denial.
- Abnormal or incomplete pre-procedure cervical screening or endometrial sampling that does not exclude malignancy/hyperplasia will trigger denial.
Background
Endometrial ablation is a minimally invasive procedure intended to treat abnormal uterine bleeding in patients who do not desire future fertility. This policy distinguishes procedures that meet defined medical necessity criteria from those that do not; specifically, it identifies certain uses (including photodynamic techniques and treatments for conditions outside the listed indications) as having insufficient scientific evidence to support effectiveness. Providers should follow the policy’s coverage criteria and contraindications when considering endometrial ablation.
Definitions
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