Anthem Blue Cross Connecticut CG-SURG-15 Endometrial Ablation Form

This document addresses endometrial ablation. Ablation or destruction of the endometrium is used to treat abnormal uterine bleeding. The U.S Food and Drug Administration (FDA) has approved devices for endometrial ablation which include, but may not be limited to: laser therapy, electrical wire loop, rollerball using electric current, thermal ablation using a liquid-filled balloon, microwave, electrode array, or a cryosurgical device.

Clinical Indications

Medically Necessary:

Endometrial ablation is considered medically necessary when the individual meets all of the following criteria (A through D):

1. Is premenopausal; and
2. Has abnormal uterine bleeding; and
3. Has any one of the following: 
   1. Failed prior hormone therapy; or
   2. Declined hormone therapy; or
   3. Contraindications to hormone therapy;
      and
4. Has no evidence of polyps or other surgically correctable cause of bleeding on sonogram or hysteroscopy.

Endometrial ablation is considered medically necessary for treatment of residual menstrual bleeding resulting from medically necessary gender affirming androgen therapy.

Not Medically Necessary:

Endometrial ablation is considered not medically necessary when the criteria above have not been met.