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AetnaAll Plans · Coverage · Medical Policy · OB-GYN, OncologyMedium impact

Endometrial Cancer Screening, Diagnosis, and Prognosis (CPB 0769, reviewed 2025-10-03)

Effective date
Not stated in the notice
Identified
Aug 14, 2026

Summary

Aetna considers endometrial biopsy medically necessary for the diagnostic evaluation of abnormal uterine bleeding in women suspected of having endometrial hyperplasia or endometrial carcinoma, and for endometrial cancer surveillance in women with Lynch syndrome. The endometrial brush (Tao brush) is an acceptable alternative to a suction curette such as the Pipelle for medically necessary sampling. Sentinel lymph node mapping is medically necessary for pathologic evaluation and surgical staging in persons with endometrial cancer and endometrial intraepithelial neoplasia (EIN), while endometrial biopsy for screening and many biomarker and genetic tests for endometrial cancer are experimental, investigational, or unproven.

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What to do

Action · 5 steps
01Billing team: Bill endometrial sampling (CPT 58100, 58110 and 58558) only for the covered indications in the policy, and bill sentinel lymph node mapping (CPT 38792 and 38900, HCPCS C7503) only for pathologic evaluation and surgical staging of endometrial cancer and EIN when the selection criteria are met.
02Use ICD-10 Z15.04 for Lynch syndrome surveillance, which the policy covers when the selection criteria are met.
03Do not bill Z12.79 for screening for endometrial cancer, because the policy does not cover it.
04Do not bill CPT 78195, 81321, 81322, 81323 or 86305 for the indications listed in the policy, because they are not covered for those indications.
05Do not bill the experimental, investigational or unproven tests listed in the policy, including endometrial biopsy for screening, PTEN immunohistochemistry for the differential diagnosis of benign and pre-malignant endometrial hyperplasia, blood AMH level for screening and diagnosis, and circulating YKL-40, serum HE4 and urine microRNAs for diagnosis.

Codes mentioned

38792389005810058110585587819581321813228132386305C7503C54.1C54.9D06.0D07.0N85.00N85.02N92.1N92.4N92.5N93.8N93.9Z15.04Z12.79

Original notice

Endometrial Cancer Screening, Diagnosis, and Prognosis (CPB 0769, reviewed 2025-10-03)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOB-GYNOncologyCode 38792Code 38900Code 58100Code 58110Code 58558Code 78195Code 81321Code 81322Code 81323Code 86305Code C7503Code C54.1Code C54.9Code D06.0Code D07.0Code N85.00Code N85.02Code N92.1Code N92.4Code N92.5Code N93.8Code N93.9Code Z15.04Code Z12.79

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