CG-SURG-15 Endometrial Ablation

This policy addresses endometrial ablation for abnormal uterine bleeding (CPT 58353, 58356, 58563). It is medically necessary when all are met: the individual is premenopausal, has abnormal uterine bleeding, and has either failed prior hormone therapy, declined hormone therapy, or has contraindications to hormone therapy; it is not medically necessary when these criteria are not met.

"Endometrial ablation is consideredmedically necessarywhen the individual meetsallof the following criteria (A through D):"

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