N84.1 — Polyp of cervix uteri
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low 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
1 Active Policy
CIGNA-0013 — Endometrial Ablation - (0013)
Related Codes
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