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Endometrial ablation is a potential alternative to hysterectomy for menorrhagia. A variety of approaches are available; these are generally classified into hysteroscopic techniques (eg, Nd-YAG laser, electrosurgical rollerball) and nonhysteroscopic techniques (eg, cryosurgical, radiofrequency [RF] ablation).
Ablation or destruction of the endometrium is used to treat menorrhagia in women who failed standard therapy. It is considered a less invasive alternative to hysterectomy; however, as with hysterectomy, the procedure is not recommended for women who wish to preserve their fertility.
Multiple energy sources have been used: (1) the neodymium-yttrium aluminum garnet (Nd-YAG) laser; (2) a resecting loop using electric current; (3) electric rollerball; and (4) thermal ablation devices. Endometrial ablation is typically preceded by hormonal treatment to thin the endometrium.
Techniques for endometrial ablation are generally divided into two categories: those that do and do not require hysteroscopic procedures. (Other terminology for these categories of techniques include first- generation versus second-generation procedures and resectoscopic versus nonresectoscopic endometrial ablation methods). Hysteroscopic techniques were developed first; the initial technique was photovaporization of the endometrium using a ND-YAG laser, and this was followed by electrosurgical ablation using an electrical rollerball or electrical wire loop. (The latter technique is also known as transcervical resection of the endometrium). Hydrothermal ablation also involves hysteroscopy. Hysteroscopic techniques require skilled surgeons and, due to the requirement for cervical dilation, use of general or regional anesthesia. In addition, the need for the instillation of hypotonic distension media creates a risk of pulmonary edema and hyponatremia such that very accurate monitoring of fluids is required.
Non-hysteroscopic techniques can be performed without general anesthesia and do not involve use of a fluid distention medium. Techniques include thermal fluid-filled balloon, cryosurgical endometrial ablation, instillation of heated saline, and radiofrequency ablation.
There are concerns about maternal and fetal morbidity and mortality associated with pregnancy after endometrial ablation. Thus, U.S. Food and Drug Administration (FDA) approval of endometrial ablation devices includes only women for whom childbearing is complete.
The FDA indicates that endometrial devices are for use in premenopausal women with menorrhagia due to benign causes for whom childbearing is complete. FDA-approved devices for endometrial ablation include, but may not be limited to, laser therapy, electrical wire loop, rollerball using electric current, and thermal ablation using a liquid-filled balloon, microwave, electrode array, or a cryosurgical device. Examples of devices for endometrial ablation are:
FDA Product Code: HHR.
POLICYEndometrial ablation, with or without hysteroscopic guidance, using an FDA-approved device may be considered medically necessary in women with menorrhagia who are not candidates for, or who are unresponsive to, hormone therapy and would otherwise be considered a candidate for hysterectomy.
Note: Intrauterine ablation or resection of the endometrium should not be confused with laparoscopic laser ablation of intraperitoneal endometriosis. This policy does not address laparoscopic intraperitoneal ablation.
Contradictions for intrauterine ablation or resection of the endometrium include:
Endometrial ablation is considered investigational for all other indications.
POLICY GUIDELINESMicrowave ablation, thermal ablation and cryoablation may be performed in an office setting.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/1992: Approved by Medical Policy Advisory Committee (MPAC)
2/1998: Reviewed with changes; new techniques described
2/1999: Reviewed with changes; new device included.
2/15/2002: Investigational definition added
3/13/2002: New 2002 code added, 4th digit added to 627
4/26/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes V10.42, 618.1-618.4 and 621.2 added
7/2003: Reviewed by MPAC, "Description" section revised to be consistent with BCBSA, policy statement specifies any FDA-approved device instead of specific statements on individual devices, "Thermal fluid-filled balloon endometrial ablation can be performed without general anesthesia and can be performed in a physician's office. The entire procedure takes about 30 minutes. Unlike other endometrial ablation techniques, thermal balloon endometrial ablation does not require hysteroscopy for guidance." deleted from "Policy Guidelines", Sources updated
3/10/2004: Code Reference section updated, CPT code 56356 deleted, ICD-9 diagnosis code 280.0 deleted
3/22/2005: Code Reference section updated, CPT code 0009T deletion date of 12/31/2004 added, CPT code 58356 with effective date 1/1/2005 added covered codes, CPT code 0071T, 0072T with effective date 1/1/2005 added non-covered codes, ICD-9 diagnosis code 618.1, 618.2, 618.3, 618.4, 621.2, V10.42 deleted non-covered codes
3/31/2005: Policy statement “Endometrial ablation, with or without hysteroscopic guidance using an FDA-approved device, may be considered medically necessary in women with menorrhagia who are not candidates for, or who are unresponsive to, hormone therapy or dilation and curettage.” changed to “Endometrial ablation, with or without hysteroscopic guidance, may be considered medically necessary in women with menorrhagia who are not candidates for, or who are unresponsive to, hormone therapy or dilation and curettage.”
3/16/2006: Policy reviewed, no changes
08/14/2010: Policy description updated regarding treatment approaches and available devices. “Dilation and curettage” removed from policy statement and “would otherwise be considered a candidate for hysterectomy” added. Policy guidelines updated to indicate that microwave ablation, thermal ablation, and cryoablation may be performed in an office setting.
08/11/2011: For clarity purposes, added a policy statement to indicate that endometrial ablation is considered investigational for all other indications. Deleted outdated references from the Sources section.
09/25/2012: Policy reviewed; no changes.
11/06/2013: Policy reviewed; no changes.
08/20/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged.
08/18/2015: Medical policy revised for ICD-10.
SOURCE(S)Blue Cross Blue Shield Association policy # 4.01.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
This may not be a comprehensive list of procedure codes applicable to this policy.