Summary
The 02/19/26 annual review of Excellus policy 4.01.01 Endometrial Ablation replaced the policy statement on using endometrial ablation for gender dysphoria with a reference to Corporate Medical Policy 3.01.22 Gender Affirming Behavioral Health and Medical Services. The policy considers endometrial ablation medically appropriate only when all listed criteria are met, including menorrhagia for more than three menstrual cycles, failure of or a contraindication to hormone therapy over three consecutive cycles, symptoms that interfere with activities of daily living or anemia unresponsive to treatment, a normal Pap smear within the past 12 months, a normal endometrium within the last six to 12 months, no pregnancy or desire for future pregnancy, and FDA approval of the device. Listed contraindications include known or suspected endometrial carcinoma, an enlarged uterus greater than 10 cm in length, submucosal myomas, active genital or urinary tract infection, and an intrauterine device in place.
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