Endometrial Ablation — CPB 0091 | AETNA Coverage Update

Aetna modified CPB 0091 for endometrial ablation, effective September 26, 2025. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its endometrial ablation coverage policy under CPB 0091 in the Aetna system. The three primary CPT codes affected are 58353 (thermal ablation without hysteroscopic guidance), 58356 (cryoablation with ultrasonic guidance), and 58563 (hysteroscopy with endometrial ablation). If your practice bills these codes for Aetna members, check your documentation checklists against the updated criteria now — before September 26, 2025.

Quick-Reference Table

Aetna Endometrial Ablation Coverage Criteria and Medical Necessity Requirements 2025

Aetna considers endometrial ablation medically necessary only when a patient meets all four of the following criteria. Miss one, and you're looking at a claim denial.

Criterion 1 — Failed or contraindicated prior treatment. The patient must have menorrhagia that didn't respond to either dilation and curettage (D&C) or hormonal/pharmacotherapy. Aetna's footnote is specific: the severity and persistence of menorrhagia must be serious enough that the member would otherwise be a hysterectomy candidate. Prior treatment attempts must have occurred within the past year.

There's a second path under Criterion 1. Aetna covers ablation to stop residual menstrual bleeding after androgen treatment in a female-to-male transgender person who meets criteria for gonadectomy under CPB 0615. Check individual plan benefit descriptions — some plans exclude coverage for gender-affirming surgery entirely.

Criterion 2 — Endometrial sampling to exclude cancer. Endometrial sampling or D&C must have been performed either on the same day as the ablation or within the year before the procedure. This step screens out cancer, pre-cancer, and hyperplasia. If the chart doesn't show this, Aetna will deny the claim.

Criterion 3 — Structural abnormalities excluded. Ultrasound must confirm the absence of fibroids or polyps that require surgery or contraindicate ablation. This imaging is typically done within the past year. No recent ultrasound? Document why an alternative method was used.

Criterion 4 — Cervical disease excluded. A current Pap smear and gynecologic exam must rule out significant cervical disease. Aetna's policy notes the Pap doesn't need to be within the past year — it just needs to be up to date per standard guidelines. That's a reasonable standard, but document it clearly.

The real issue with this coverage policy is the "all four" requirement. Each criterion has its own documentation and timing rule. One expired test or a missing chart note will trigger a denial. This is the kind of policy where prior authorization requests get rejected not because the patient doesn't qualify, but because the documentation packet was incomplete.

If your team is unsure whether existing pre-authorization workflows capture all four criteria, review your prior authorization intake checklist before the effective date of September 26, 2025.

Aetna Endometrial Ablation Exclusions and Non-Covered Indications

Aetna's position is direct: endometrial ablation is experimental, investigational, or unproven for all indications other than menorrhagia that meets the criteria above.

Post-menopausal bleeding is the specific example Aetna calls out. If a provider orders ablation for a post-menopausal patient — regardless of the clinical rationale — Aetna will not cover it. Full stop.

This also means reimbursement is off the table for any off-label application of CPT 58353, 58356, or 58563. If you're billing these codes with diagnosis codes that don't point to qualifying menorrhagia (or the specific transgender indication), expect denial. Train your coders to flag mismatches between the ablation CPT and the supporting ICD-10 before the claim goes out.

CPT codes 76376 and 76377 (3D rendering for CT, MRI, or ultrasound) are explicitly not covered for indications listed in CPB 0091. Don't bundle these with ablation claims expecting reimbursement.

Coverage Indications at a Glance

Aetna Endometrial Ablation Billing Guidelines and Action Items 2025

These are the steps your billing team needs to take. Don't wait until October to start.

1. Update your documentation checklist before September 26, 2025.
Build a four-point checklist that mirrors Aetna's criteria exactly: failed/contraindicated prior treatment, endometrial sampling within 12 months, ultrasound excluding structural abnormalities, and current Pap/cervical exam. Attach this to every ablation order at the time of scheduling.

2. Verify prior authorization requirements at the plan level.
CPB 0091 sets Aetna's clinical criteria, but individual plan contracts control prior authorization requirements. Check each member's plan before the procedure. Don't assume that because the patient clinically qualifies, prior auth isn't required.

3. Confirm the correct CPT code for the approach used.
CPT 58353 covers thermal ablation without hysteroscopic guidance — but it's not covered when performed at the same time as a hysteroscopy. CPT 58563 covers hysteroscopy with endometrial ablation. CPT 58356 covers cryoablation with ultrasonic guidance, and includes endometrial curettage when performed. Use the right code for the approach. A mismatch here is a fast path to a claim denial.

4. Remove CPT 76376 and 76377 from ablation billing bundles.
These 3D rendering codes are explicitly not covered for CPB 0091 indications. If your charge capture automatically bundles imaging codes with ablation procedures, audit that configuration now. Billing these codes with ablation claims will generate denials and may trigger audit scrutiny.

5. Audit the timing documentation on pre-procedure workup.
Endometrial sampling must be within 12 months. Ultrasound must be within 12 months. The Pap smear needs to be current — not necessarily within 12 months, but up to date per screening guidelines. Build date-check prompts into your prior auth workflow so a provider doesn't submit for a procedure when the workup has lapsed.

6. Flag transgender patient cases for benefit verification.
Coverage for the transgender indication under CPB 0615 is contingent on the procedure qualifying under the gender-affirming surgery benefit. Many Aetna plans exclude this benefit entirely. If your practice sees this patient population, do a benefits check at the individual plan level before scheduling. This is a scenario where you should talk to your compliance officer before billing if you're unsure how your payer mix handles this.

7. Check corpus uteri excision codes against histopathological report findings.
CPT codes 57558 and 58100 through 58120 (corpus uteri excision and related codes) are covered only when the histopathological report from the endometrial sampling supports medical necessity. If a patient proceeds to hysterectomy following ablation workup, the path from ablation to surgical management needs a documented clinical reason tied back to that sampling report.

CPT, HCPCS, and ICD-10 Codes for Endometrial Ablation Under CPB 0091

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes