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Date Printed: August 18, 2017: 10:26 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-56000-29

Original Effective Date: 05/15/02

Reviewed: 10/19/16

Revised: 11/15/16

Subject: Endometrial Ablation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Endometrial ablation is used to treat abnormal uterine bleeding. Several techniques are used to perform endometrial ablation: radiofrequency, freezing, heated fluid, heated balloon, microwave energy and electrosurgery; these techniques are performed with or without hysteroscopic guidance.

Ablation or destruction of the endometrium is used to treat abnormal uterine bleeding in women who failed medical therapy (e.g., hormonal therapy, dilatation and curettage (D&C)). Endometrial ablation is considered a less invasive alternative to hysterectomy; as with hysterectomy, endometrial ablation is not recommended for women who desire future fertility.

There are several medical devices approved by the U.S. Food and Drug Administration (FDA) for endometrial ablation which include, but not limited to the Hydro ThermAblaton┬« system, Microwave Endometrial Ablation (MEA), ThermaChoice┬« device, NovaSure™ and Her Option™ Uterine Cryoablation Therapy™.

Two laparoscopic surgical approaches are proposed as adjuncts to conservative surgical therapy for the treatment of primary and secondary dysmenorrhea. These approaches are laparoscopic uterine nerve ablation (LUNA), also known as uterine nerve ablation (UNA) and presacral neurectomy (PSN). UNA and PSN have been investigated as techniques to interrupt most of the cervical sensory nerve fibers in patients with dysmenorrhea. UNA involves the transection of the uterosacral ligaments at their insertion into the cervix, while PSN involves removal of the presacral nerves lying within the interiliac triangle. PSN interrupts a greater number of nerve pathways compared with LUNA, and is technically more demanding. Either LUNA or PSN can be performed as adjuncts to conservative surgical therapy in patients with secondary dysmenorrhea.

The evidence is insufficient to form conclusions on whether laparoscopic uterine nerve ablation (LUNA) improves health outcomes in patients with primary or secondary dysmenorrhea. Also, the evidence on presacral neurectomy (PSN) for treating primary dysmenorrhea is insufficient to form conclusions on whether PSN improves health outcomes.

POSITION STATEMENT:

Endometrial ablation, with or without hysteroscopic guidance, using an FDA-approved device meets the definition of medical necessity in members with abnormal uterine bleeding when ALL of the following are met:

Member is considered a candidate for hysterectomy (member does not have a contraindication); AND

ONE of the following must be met:

Member is not a candidate for hormone therapy; OR

Member is unresponsive to hormone therapy.

Endometrial ablation is considered experimental or investigational for all other indications:

Laparoscopic uterine nerve ablation (LUNA); including uterine nerve ablation (UNA) and presacral neurectomy (PSN) is considered experimental or investigational for all indications. The evidence is insufficient to determine the impact of laparoscopic uterine nerve ablation (LUNA); including uterine nerve ablation (UNA) and presacral neurectomy (PSN) on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

58353

Endometrial ablation, thermal, without hysteroscopic guidance

58356

Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed

58563

Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation)

NOTE: There is no specific CPT or HCPCS code for uterine nerve ablation (UNA), laparoscopic uterine nerve ablation (LUNA) or presacral neurectomy (PSN). CPT code 58578 (unlisted laparoscopy procedure, uterus) may be used to report UNA or LUNA.

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

N80.0 – N80.9

Endometriosis

N89.7

Hematocolpos

N92.0-N92.2
N92.4-N92.6

Excessive, frequent and irregular menstruation

N93.8

Other specified abnormal uterine and vaginal bleeding

N95.0

Postmenopausal bleeding

REIMBURSEMENT INFORMATION:

None applicable.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Amenorrhea: absence of menstruation.

Dysfunctional uterine bleeding: abnormal bleeding for which no specific cause has been found.  It most often implies a mechanism of anovulation, although not all bleeding that is outside the normal range (either in cycle length or duration) is anovulatory.

Menopause: cessation of menstruation in the female, occurring usually around the age of 50.

Menorrhagia: excessive or frequent uterine bleeding during the menstrual period.

Postmenopausal menorrhagia: uterine bleeding six months or more after the last normal menstrual period at menopause.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report endometrial ablation:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of
one product over another, and is not intended to represent a complete listing of all products available.

Intrauterine Ablation
Laser Ablation of the Endometrium
Thermal Fluid-Filled Balloon Endometrial Ablation
ThermaChoice
Thermal Liquid-Filled Balloon Endometrial Ablation
Rollerball Ablation of the Endometrium

REFERENCES:

  1. AHRQ/National Guideline Clearinghouse. NGC-007874. An evidence based practice guideline for the treatment of primary dysmenorrhea. University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. 10/21/10.
  2. American College of Obstetricians and Gynecologists. Endometrial Ablation. 2007 ACOG Practice Bulletin No. 81.
  3. American College of Obstetricians and Gynecologists. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. Committee Opinion Number 557; 2013.
  4. American Society for Reproductive Medicine Fact Sheet Endometrial Ablation, 2011.
  5. Bain C, Cooper KG, Parkin DE. Microwave endometrial ablation versus endometrial resection: a randomized controlled trial. Obstetrics & Gynecology 2002; 99(6): 983-987.
  6. Blue Cross Blue Shield Association Medical Policy Reference Manual. Endometrial Ablation 4.01.04, 08/16.
  7. Blue Cross Blue Shield Association Medical Policy Reference Manual Surgical Interruption of Pelvic Nerve Pathways for Primary and Secondary Dysmenorrhea 4.01.17, 04/15.
  8. Cooper J, Gimpelson R, Laberge P et al. A randomized, multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. Journal of the American Association of Gynecologic Laparoscopists 2002; 9(4): 418-428.
  9. Corson SL. A multicenter evaluation of endometrial ablation by Hydro ThermAblator and rollerball for treatment of menorrhagia. Journal of the American Association of Gynecologic Laparoscopists 2001; 8(3): 359-367.
  10. Daniels J, Gray R, Hills R, Latthe P, Buckley L, Gupta J, Selman T, Adey E, Xiong T, Champaneria R, Lilford R, Khan K. Laparoscopic Uterosacral Nerve Ablation for Alleviating Chronic Pelvic Pain. A Randomized Controlled Trial. JAMA, 2009—Vol 302, No. 9.
  11. Daniels JP, Middleton LJ, Champaneria R et al. Second generation endometrial ablation techniques for heavy menstrual bleeding: network meta-analysis. British Medical Journal 2012; 344: e2564.
  12. Dood RL, Gracia CR, Sammel MD et al. Endometrial cancer after endometrial ablation vs medical management of abnormal uterine bleeding. Journal of Minimally Invasive Gynecology 2014; 21(5): 744-752.
  13. Duleba AJ, Heppard MC, Soderstrom RM et al. A randomized study comparing endometrial cryoablation and rollerball electroablation for treatment of dysfunctional uterine bleeding. Journal of the American Association of Gynecologic Laparoscopists 2003; 10(1): 17-26.
  14. El-Din SH. The efficacy of laparoscopic uterosacral nerve ablation (LUNA) in the treatment of unexplained chronic pelvic pain: a randomized controlled trial. Gynecological Surgery 2011; 8(1): 31-39.
  15. Iglesias DA, Madani Sims S, Davis JD. The effectiveness of endometrial ablation with the Hydro ThermAblator (HTA) for abnormal uterine bleeding. American Journal of Obstetrics & Gynecology 2010; 202(6): 622e1-622e6.
  16. National Institute for Health and Clinical Excellence (NICE). Heavy menstrual bleeding. Clinical Guideline, January 2007.
  17. National Institute for Health and Clinical Evidence (NICE). Laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain. NICE Interventional Procedure Guidance 234. 2007.
  18. Nezhat F, Levinson D. Chronic Pelvic Pain. Society of Laparoendoscopic Surgeons, Prevention and Management, 1st Edition. 2006.
  19. NHS National Institute for Clinical Health and Excellence. Laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain (interventional procedures consultation). 03/30/10.
  20. Practice Committee of the American Society for Reproductive Medicine. Indications and options for endometrial ablation. Fertility and Sterility 2008; 90(3): S236-S240.
  21. Redwine D. Complications of LUNA and Presacral Neurectomy by Laparoscopy. Society of Laparoendoscopic Surgeons, Prevention and Management, 1st Edition. 2006.
  22. Sutton CJ, Pooley AS, Ewen SP et al. Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis. Fertility and Sterility 1997; 68(6): 1070-1074.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/19/16.

GUIDELINE UPDATE INFORMATION:

05/15/02

New Medical Coverage Guideline.

08/15/02

Deleted cryoprobes from when services are not covered.

10/01/02

Added cryosurgical device with hysteroscopic guidance to WHEN SERVICES ARE COVERED. Deleted the word investigational from the CPT coding section for 0009T.

05/15/03

Annual review.

11/13/03

Added diagnoses codes: 621.0, 622.7, and 627.1 to the list of covered diagnosis.

04/15/04

Added diagnoses 626.6 and 626.8. Annual review.

01/01/05

HCPCS update. Deleted 0009T and Added 58356.

01/15/05

Annual review; next review changed to NLR; no change in coverage.

03/15/05

Deleted reference to InterQual Criteria (Ablation/Excision, Endometrosis, Laparoscopic, OBG-1).

07/15/11

Guideline reviewed and guideline status changed to active. Revised the description and position statement. Updated ICD-9 codes. Added ICD-10 related codes. Updated references.

10/15/11

Revision; added experimental/investigational coverage statement for uterine nerve ablation (UNA)/laparoscopic uterine nerve ablation (LUNA). Updated description section, billing/coding section and references.

04/01/12

Reformatted and revised position statement for clarity.

01/15/13

Annual review; no change to position statement. Added experimental or investigational statement (for all other indications) for endometrial ablation.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; updated ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

11/15/16

Revision; updated description and references and revised position statement.

Date Printed: August 18, 2017: 10:26 AM