Aetna Endometrial Ablation coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Aetna considers endometrial ablation medically necessary for women who meet ALL of the following selection criteria (Criteria 1-4):
• Criterion 1: Menorrhagia unresponsive to (or with a contraindication to) ONE of the following: dilation and curettage (D&C); OR hormonal therapy or other pharmacotherapy. The degree of severity and persistence of the menorrhagia and the failure of prior treatment should be such that the member would otherwise be a candidate for hysterectomy; these alternative less invasive approaches should have been attempted in the past year.
• Criterion 1 (alternative indication): Endometrial ablation to stop residual menstrual bleeding after androgen treatment in a female-to-male transgender person who meets criteria for gonadectomy per CPB 0615 (note: some plans exclude coverage of surgery for gender reassignment; check benefit plan descriptions).
• Criterion 2: Endometrial sampling or D&C has been performed on the same day or within the year prior to the procedure to exclude cancer, pre-cancer or hyperplasia.
• Criterion 3: Structural abnormalities (fibroids, polyps) that require surgery or represent a contraindication to an ablation procedure have been excluded (this is almost always done by ultrasound in the past year).
• Criterion 4: Pap smear and gynecologic examination have excluded significant cervical disease (the Pap smear should be up to date, so not necessarily within the past year).
• Established/medically necessary ablation technique (for women meeting the above criteria): Chemical ablation with trichloroacetic acid.
• Established/medically necessary ablation technique: Cryoablation (freezing) (e.g., Her Option Cryoablation Therapy).
• Established/medically necessary ablation technique: Electrosurgical/electrocautery ablation (electric rollerball, resecting loop, triangular mesh).
• Established/medically necessary ablation technique: Laser ablation.
• Established/medically necessary ablation technique: Microwave endometrial ablation (e.g., Microsulis MEA System).
• Established/medically necessary ablation technique: Minitouch System.
• Established/medically necessary ablation technique: Radiofrequency ablation (e.g., NovaSure Procedure, Minerva Endometrial Ablation System).
• Established/medically necessary ablation technique: Thermoablation/hydrothermal/balloon therapy ablation (heated saline, thermal fluid-filled balloon).

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 58353·PA verdict·Rate
• 58356·PA verdict·Rate
• 58563·PA verdict·Rate

Documentation required

• Endometrial sampling or D&C results performed the same day or within the year prior to the procedure to exclude cancer, pre-cancer or hyperplasia.
• Ultrasound (typically within the past year) confirming exclusion of structural abnormalities such as fibroids or polyps that require surgery or contraindicate ablation.
• Pap smear and gynecologic examination results excluding significant cervical disease (Pap smear up to date, not necessarily within the past year).
• Documentation of prior treatment failure: menorrhagia unresponsive to (or contraindication to) D&C and/or hormonal/pharmacologic therapy attempted in the past year.

Frequently asked questions

When does Aetna cover Endometrial Ablation (CPT 58353), and what gets it denied?

Aetna covers endometrial ablation as medically necessary for women with menorrhagia that is unresponsive to (or has a contraindication to) D&C or hormonal/drug therapy and who would otherwise be hysterectomy candidates, provided cancer/hyperplasia has been excluded by recent endometrial sampling or D&C, structural abnormalities (fibroids/polyps) have been ruled out (usually by ultrasound), and an up-to-date Pap smear excludes significant cervical disease. Multiple ablation techniques (e.g., radiofrequency, cryoablation, thermal balloon, microwave) are considered established, while all other indications (such as post-menopausal bleeding), ablation for fertility control, photodynamic ablation, simultaneous hysteroscopic sterilization with RF ablation, and certain other items are experimental/investigational/unproven. Coverage criteria include: Aetna considers endometrial ablation medically necessary for women who meet ALL of the following selection criteria (Criteria 1-4):; Criterion 1: Menorrhagia unresponsive to (or with a contraindication to) ONE of the following: dilation and curettage (D&C); OR hormonal therapy or other pharmacotherapy. The degree of severity and persistence of the menorrhagia and the failure of prior treatment should be such that the member would otherwise be a candidate for hysterectomy; these alternative less invasive approaches should have been attempted in the past year.; Criterion 1 (alternative indication): Endometrial ablation to stop residual menstrual bleeding after androgen treatment in a female-to-male transgender person who meets criteria for gonadectomy per CPB 0615 (note: some plans exclude coverage of surgery for gender reassignment; check benefit plan descriptions).; Criterion 2: Endometrial sampling or D&C has been performed on the same day or within the year prior to the procedure to exclude cancer, pre-cancer or hyperplasia.; Criterion 3: Structural abnormalities (fibroids, polyps) that require surgery or represent a contraindication to an ablation procedure have been excluded (this is almost always done by ultrasound in the past year).; Criterion 4: Pap smear and gynecologic examination have excluded significant cervical disease (the Pap smear should be up to date, so not necessarily within the past year).; Established/medically necessary ablation technique (for women meeting the above criteria): Chemical ablation with trichloroacetic acid.; Established/medically necessary ablation technique: Cryoablation (freezing) (e.g., Her Option Cryoablation Therapy).; Established/medically necessary ablation technique: Electrosurgical/electrocautery ablation (electric rollerball, resecting loop, triangular mesh).; Established/medically necessary ablation technique: Laser ablation.; Established/medically necessary ablation technique: Microwave endometrial ablation (e.g., Microsulis MEA System).; Established/medically necessary ablation technique: Minitouch System.; Established/medically necessary ablation technique: Radiofrequency ablation (e.g., NovaSure Procedure, Minerva Endometrial Ablation System).; Established/medically necessary ablation technique: Thermoablation/hydrothermal/balloon therapy ablation (heated saline, thermal fluid-filled balloon).. Applies to 3 codes: 58353, 58356, 58563. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Endometrial sampling or D&C results performed the same day or within the year prior to the procedure to exclude cancer, pre-cancer or hyperplasia.; Ultrasound (typically within the past year) confirming exclusion of structural abnormalities such as fibroids or polyps that require surgery or contraindicate ablation.; Pap smear and gynecologic examination results excluding significant cervical disease (Pap smear up to date, not necessarily within the past year).; Documentation of prior treatment failure: menorrhagia unresponsive to (or contraindication to) D&C and/or hormonal/pharmacologic therapy attempted in the past year. Policy exclusions and limitations: Aetna considers endometrial ablation experimental, investigational, or unproven for all other indications (e.g., post-menopausal bleeding) because its effectiveness for other indications has not been established.; Endometrial ablation for post-menopausal bleeding is experimental, investigational, or unproven.; 3D pelvic ultrasound for measurement of endometrial cavity length before endometrial ablation is experimental, investigational, or unproven.; Combined endometrial ablation and levonorgestrel-releasing intrauterine system for treatment of heavy menstrual bleeding is experimental, investigational, or unproven.; Endometrial ablation for unwanted fertility is experimental, investigational, or unproven.; Hysteroscopic sterilization performed simultaneously with radiofrequency endometrial ablation is experimental, investigational, or unproven (ablation has been shown to decrease the success rate of sterilization).; Photodynamic endometrial ablation is experimental, investigational, or unproven.; Contraindication / non-coverage: Women with endometrial hyperplasia or uterine cancer should not undergo endometrial ablation (per cited ACOG guidance).; Contraindication: Structural abnormalities (fibroids, polyps) that require surgery or represent a contraindication to an ablation procedure must be excluded before ablation. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Endometrial Ablation?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Endometrial sampling or D&C results performed the same day or within the year prior to the procedure to exclude cancer, pre-cancer or hyperplasia.; Ultrasound (typically within the past year) confirming exclusion of structural abnormalities such as fibroids or polyps that require surgery or contraindicate ablation.; Pap smear and gynecologic examination results excluding significant cervical disease (Pap smear up to date, not necessarily within the past year).; Documentation of prior treatment failure: menorrhagia unresponsive to (or contraindication to) D&C and/or hormonal/pharmacologic therapy attempted in the past year.

What does Aetna exclude for Endometrial Ablation?

Policy exclusions and limitations: Aetna considers endometrial ablation experimental, investigational, or unproven for all other indications (e.g., post-menopausal bleeding) because its effectiveness for other indications has not been established.; Endometrial ablation for post-menopausal bleeding is experimental, investigational, or unproven.; 3D pelvic ultrasound for measurement of endometrial cavity length before endometrial ablation is experimental, investigational, or unproven.; Combined endometrial ablation and levonorgestrel-releasing intrauterine system for treatment of heavy menstrual bleeding is experimental, investigational, or unproven.; Endometrial ablation for unwanted fertility is experimental, investigational, or unproven.; Hysteroscopic sterilization performed simultaneously with radiofrequency endometrial ablation is experimental, investigational, or unproven (ablation has been shown to decrease the success rate of sterilization).; Photodynamic endometrial ablation is experimental, investigational, or unproven.; Contraindication / non-coverage: Women with endometrial hyperplasia or uterine cancer should not undergo endometrial ablation (per cited ACOG guidance).; Contraindication: Structural abnormalities (fibroids, polyps) that require surgery or represent a contraindication to an ablation procedure must be excluded before ablation. Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT