No active policy covers this code (high confidence)
Documentation Required
endometrial evaluation by biopsy, dilatation and curettage (D&C) fails to show evidence of remediable pathology
diagnostic evaluation of the uterine cavity by ultrasound, sonohysterogram or hysteroscopy failed to show evidence of remediable pathology
documentation of failure, intolerance or contraindication of hormonal treatment for at least three months
documentation that intrauterine devices (IUD) have been removed and that medical evaluation and management has been used to control the bleeding
Key Coverage Criteria
Endometrial ablation is considered medically necessary as an alternative to hysterectomy for the treatment of menorrhagia or excessive anovulatory bleeding.
Endometrial ablation is considered medically necessary for residual menstrual bleeding after androgen treatment in an individual with confirmed gender dysphoria undergoing female to male hormonal sex reassignment* therapy.
uterus size of < 12 weeks' gestation (i.e., uterine length of less than 13 centimeters [cm] and anterior-posterior width of less than 7 cm )
failure, intolerance or contraindication of hormonal treatment for at least three months
endometrial evaluation by biopsy, dilatation and curettage (D&C) fails to show evidence of remediable pathology
diagnostic evaluation of the uterine cavity by ultrasound, sonohysterogram or hysteroscopy failed to show evidence of remediable pathology