N92.6 — Irregular menstruation, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
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).
6 Active Policies
AMBETTER-CP.MP.106 — Endometrial Ablation
AETNA-CPB-0091 — Endometrial Ablation
AETNA-CPB-0327 — Infertility
ANTHEM-CG-MED-84 — CG-MED-84 Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting
ANTHEM-CG-LAB-20 — CG-LAB-20 Thyroid Testing
Related Codes
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