J7298, Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation that endometrial sampling or dilation and curettage (D&C) was performed within the year prior to the ablation to exclude cancer, pre-cancer or hyperplasia, and that the histopathological report/results have been reviewed before scheduling the ablation.
- Documentation that structural abnormalities (fibroids, polyps) that require surgery or represent a contraindication to an ablation procedure have been excluded (typically by transvaginal/transabdominal ultrasound) within the past year.
- Documentation of Pap smear and gynecologic examination excluding significant cervical disease (Pap smear should be up to date; not necessarily within past year).
- Documentation of prior treatments attempted (D&C and/or hormonal therapy/other pharmacotherapy) within the past year and either failure of those treatments or a documented contraindication to them; documentation that the patient’s degree of severity/persistence of menorrhagia would otherwise make her a candidate for hysterectomy.
Key Coverage Criteria
- Endometrial ablation is medically necessary for women with menorrhagia who meet ALL selection criteria (see policy).
- Menorrhagia (excessive, frequent and/or irregular menstruation) unresponsive to (or with a contraindication to) either dilation and curettage or hormonal therapy/other pharmacotherapy.
- Endometrial ablation when the degree of severity and persistence of menorrhagia and failure of prior treatment are such that the member would otherwise be a candidate for hysterectomy (alternative less invasive approaches should have been attempted in the past year).
- Endometrial ablation to stop residual menstrual bleeding after androgen treatment in a female-to-male transgender person who meets criteria for gonadectomy in CPB 0615 - Gender Affirming Surgery (note: some plans exclude coverage of gender reassignment surgery; check benefit plan).
- Endometrial ablation performed by any of the following established approaches for members who meet the selection criteria: chemical ablation with trichloroacetic acid; cryoablation (e.g., Her Option Cryoablation Therapy); electrosurgical/electrocautery ablation (e.g., electric rollerball, resecting loop, triangular mesh); laser; microwave endometrial ablation (Microsulis MEA System); radiofrequency ablation (NovaSure, Minerva); thermoablation/hydrothermal/balloon therapies (e.g., Genesys HydroTh [...]
- CPT codes covered when selection criteria are met: 58353 (Endometrial ablation, thermal, without hysteroscopic guidance), 58356 (Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed), 58563 (Hysteroscopy, surgical; with endometrial ablation).
5 Active Policies
UHC-POL-abnormal-uterine-bleeding-uterine-fibroids, Abnormal Uterine Bleeding and Uterine Fibroids
AETNA-CPB-0091, Endometrial Ablation
CIGNA-A004, Preventive Care Services
UMR-POL-UMR-abnormal-uterine-bleeding-uterine-fibroids, Abnormal Uterine Bleeding and Uterine Fibroids
SUREST-POL-SUREST-abnormal-uterine-bleeding-uterine-fibroids
Related Codes
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