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Medical Policy: 04.01.01
Original Effective Date: July 2002
Reviewed: May 2012
Revised: July 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Endometrial ablation is used as an alternative to hysterectomy to treat menorrhagia, or heavy menstrual bleeding, in women who have failed hormone therapy or dilation and curettage. It is considered a less invasive alternative; however, as with hysterectomy, the procedure is not recommended for women who wish to preserve their fertility.
Several techniques have been developed to ablate the lining of the endometrium. First-generation techniques require hysteroscopy and include laser, transcervical resection of the endometrium, and electric rollerball. These procedures require skilled surgeons and, due to the requirement for cervical dilation, use of general or regional anesthesia. In addition, the need for the instillation of hypotonic distension media creates a risk of pulmonary edema and hyponatremia such that very accurate monitoring of fluids is required. Second-generation techniques can be performed without general anesthesia and do not involve use of a fluid distension medium. Techniques include microwave ablation, thermal balloon ablation, radiofrequency electrosurgery, hydrothermal ablation, and cryoablation.
Note: Intrauterine ablation or resection of the endometrium should not be confused with laparoscopic laser ablation of intraperitoneal endometriosis. This policy does not address laparoscopic intraperitoneal ablation.
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Prior Approval:
Not applicable
However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.
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Policy:
Endometrial ablation, with or without hysteroscopic guidance, using an FDA-approved device may be considered medically necessary in women with menorrhagia who are not candidates for, or who are unresponsive to, hormone therapy or dilation and curettage.
There is evidence from multiple randomized controlled trials that endometrial ablation improves the net health outcome in women who have failed prior treatments for menorrhagia and are otherwise eligible for hysterectomy. Moreover, meta-analysis of RCTs suggest similar benefits with first-generation techniques and second-generation techniques. There is a lack of consistent evidence that any one ablation technique is superior to another.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 58353 endometrial ablation, thermal, without hysteroscopic guidance.
- 58563 hysteroscopy with endometrial ablation (it includes radiofrequency, cryoprobe, balloon, microwave).
- 58356 endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
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Selected References:
- Bridgman SA, Dunn KM. Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures. British Journal of Obstetrics and Gynecology April 2000; 107:531-534.
- Jones K, Abbott J, Hawe J, Sutton C, Garry R. Endometrial laser intrauterine thermotherapy for the treatment of dysfunctional uterine bleeding: the first British experience. British Journal of Obstetrics and Gynecology July 2001; 108:749-753.
- Aberdeen endometrial ablation trials group. A randomized trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years. British Journal of Obstetrics and Gynecology April 1999; 106:360-366.
- Abbott JA, Garry R. The surgical management of menorrhagia. Human Reproduction Update 2002 Jan-Feb; 8(1):68-78.
- Farquhar CM, Naoom S, Steiner CA. The impact of endometrial ablation on hysterectomy rates in women with benign uterine conditions in the United States. International Journal of Technology Assessment in Health Care 2002;18(3):625-634.
- Busund B, Erno LE, Gronmark A, Istre O. Endometrial ablation with NovaSure GEA, a pilot study. Acta Obstet Gynecol Scand 2003 Jan;82(1):65-8.
- BongersMY, Mol BW, Brolmann HA. Prognostic factors for the success of thermal balloon ablation in the treatment of menorrhagia. Obstet Gynecol 2002 Jun;99(6):1060-6.
- HaweJ, Abbott J, Hunter D, Phillips G, Garry R. A randomized controlled trial comparing the Cavaterm endometrial ablation system with the Nd:YAG laser for the treatment of dysfunctional uterine bleeding. BJOG 2003 Apr;110(4):350-7.
- Cooper KG, Bain C, Lawrie L, Parkin DE. A randomized comparison of microwave endometrial ablation with transcervical resection of the endometrium; follow up at a minimum of five years. BJOG. 2005 Apr;112(4):470-5.
- Cooper JM, Anderson TL, Fortin CA et al. Microwave endometrial ablation vs. rollerball electrobablation for menorrhagia: a multicenter randomized trial. J Am Assoc Gynecol Laparosc. 2004 Aug; 11(3): 394-403.
- Bongers MY, Bourdrez P, Mol BW et al. Randomized controlled trial of bipolar radio-frequency endometrial ablation and ballon endometrial ablation. BJOG. 2004 Oct; 111(10): 1095-102.
- Neuwirth RS, Loffer FD, Trenhaile T, Levin B. The incidence of endometrial ablation in a low-risk population. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):492-4.
- Dillon A; Photodynamic endometrial ablation.National Health Service’s National Institute for Clinical Excellence Interventional Procedure Guidance 47; March 2004. Available from www.nice.org.uk/IP078overview.
- Kucukozkan T, Kadioglu BG, et al. Chemical ablation of endometrium with trichloroacetic acid. Int J Gynaecol Obstet. 2004 Jan;84(1):41-6.
- Kucuk M, Okman TK. Intrauterine instillation of trichloroacetic acid is effective for the treatment of dysfunctional uterine bleeding. Fertil Steril. 2005 Jan;83(1):189-94.
- National Institute for Health and Clinical Excellence (NICE). Interventional procedure guidance 47: photodynamic endometrial ablation. Updated March 2004. Available at URL address: http://www.nice.org.uk/pdf/IPG047guidance.pdf
- ECRI Institute. Impedence-controlled Radiofrequency System for Endometrial Ablation. Plymouth Meeting (PA): ECRI Institute; 2009 Oct 27. 9 p. [ECRI hotling response]. Also available: http//www.ecri.org.
- Bhattachara S, Middleton TJ, Tsourapas A et al. Hysterectomy, endometrial ablation and Mirena for heavy menstrual bleeding: a systematic review of clinical effectiveness and cost effectivenessanalysis. Health Technology Assessment 2011; Vol. 15. No. 19. Available at: http://www.hta.ac.uk/fullmono/mono1519.pdf.
- Clark TJ, Samuel N, Malick S et al. Bipolar radiofrequency ccompared with thermal balloon endometrial ablation in the office. Obstet Gynecol 2011; 117(1):109-18.
- Daniels JP, Middleton LJ, Champaneria R et al. Second-generation endometrial ablation techniques for heavy menstrual bleeding: network meta-analysis. BMJ. 2012 Apr 23; 344:e2564. doi: 10.1136/bmj.e2564.
- Pollock W, Jamieson W. Next-generation NovaSure device for endometrial ablation: assessing ease-of-use among physicians. Int J Womens Health. 2012; 4:109-13. Epub 2012 Mar 14.
- Fernandez H. Update on the management of menometrorrhagia: new surgical approaches. Gynecol Endocrinol. 2011 Dec; 27 Suppl 1:1131-6. Epub 2011 Dec 1.
- Penninx JP, Herman MC, Mol BW et al. Five-year follow-up after comparing bipolar endometrial ablation with hydrothermablation for menorrhagia. Obstet Gynecol. 2011 Dec; 118(6):1287-92.
- Wheeler TL 2nd, Murphy M, Rogers RG et al. Clinical practice guideline for abnormal uterine bleeding: hysterectomy versus alternative therapy. J Minim Invasive Gynecol. 2012 Jan-Feb; 19(1):81-8. Epub 2011 Nov 11.
- Matteson KA, Abed H, Wheeler TL 2nd et al. A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding. J Minim Invasive Gynecol. 2012 Jan-Feb; 19(1):13-28. Epub 2011 Nov 11.
- Munro MG, Dickersin K, Clark MA et al. The Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding: summary of an Agency for Health Research and Quality-sponsored randomized trial of endometrial ablation versus hysterectomy for women with heavy menstrual bleeding. Menopause. 2011 Apr; 18(4):445-52.
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Policy History:
Date Reason Action
July 2011 Annual review Policy renewed
May 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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