![]() ![]() ![]() Hysteroscopy, surgical with sampling(biopsy) of endometrium and/or polypectomy, with or without D&C Hysteroscopy, surgical with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation)ĭilation and curettage of cervical stump ĭilation of cervical canal, instrumental (separate procedure)Ĭorpus uteri excision Codes requiring a 7th character are represented by "+":ĬPT codes covered if selection criteria are met:Įndometrial ablation, thermal, without hysteroscopic guidance Įndometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed Information in the below has been added for clarification purposes. Table: CPT Codes / HCPCS Codes/ ICD-10 Codes Code Combined endometrial ablation and levonorgestrel-releasing intrauterine system for the treatment of heavy menstrual bleeding.Hysteroscopic sterilization when performed at the same time as radiofrequency endometrial ablation, as ablation has been shown to decrease the sucess rate of sterilization.The following procedures are considered experimental and investigational because the effectiveness of these approaches has not been established: Thermoablation/hydrothermal ablation/balloon therapy ablation (e.g., heated saline (Genesys HydroThermAblator), thermal fluid-filled balloon (Gynecare Thermachoice)).Radiofrequency ablation (The NovaSure Procedure, and the Minerva Endometrial Ablation System).Microwave endometrial ablation (Microsulis Microwave Endometrial Ablation (MEA) System).Electrosurgical ablation/electrocautery ablation (e.g., electric rollerball, resecting loop with electric current, triangular mesh with electrical current).Cryoablation (freezing) (Her Option Cryoablation Therapy).Chemical ablation with trichloroacetic acid.Aetna considers the following endometrial ablation approaches to be established for treatment of women who meet the selection criteria set forth above:.Note: The Pap smear should be up to date so not necessarily within the past year.Īetna considers endometrial ablation experimental and investigational for all other indications (e.g., post-menopausal bleeding) because its effectiveness for other indications has not been established. Pap smear and gynecologic examination have excluded significant cervical disease.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) and.Endometrial sampling or D&C has been performed within the year prior to the procedure to exclude cancer, pre-cancer or hyperplasia, and the results of the histopathological report have been reviewed before the ablation procedure is scheduled (should be done in the past year) and.Note: Some plans exclude coverage of surgery for gender reassignment please check benefit plan descriptions and ![]() Hormonal therapy or other pharmacotherapy įootnotes* Note: 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 a hysterectomy these alternative less invasive approaches should have been attempted in the past year orĮndometrial ablation is to be used 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.Menorrhagia Footnotes* unresponsive to (or with a contraindication to) either:.Endometrial ablation is considered medically necessary for women who meet all of the following selection criteria:.This Clinical Policy Bulletin addresses endometrial ablation.Īetna considers the following medically necessary: Number: 0091 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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