Is Endometrial Biopsy Covered By Insurance and Fibroids: What to Know

If you’re dealing with abnormal uterine bleeding, pelvic pain, or planning treatment for fibroids, your clinician may recommend an endometrial biopsy. It’s a quick office procedure that samples the uterine lining to help rule out conditions like endometrial hyperplasia or cancer. Understandably, many patients wonder: Is it covered by insurance, how much might it cost, and why is it done when fibroids are the main issue? Here’s what to know, with guidance from trusted health sources.

What an Endometrial Biopsy Is—and Why It’s Ordered with Fibroids

An endometrial biopsy uses a thin, flexible catheter to collect a small tissue sample from the uterine lining (endometrium). The sample is examined by a pathologist to check for precancerous changes (hyperplasia) or cancer. According to MedlinePlus and the National Cancer Institute, endometrial sampling is a standard, reliable way to evaluate unexplained or heavy bleeding and to assess for endometrial cancer when indicated.^1,2

Fibroids (benign growths of the uterus) commonly cause heavy or prolonged menstrual bleeding and cramping. Imaging—usually a transvaginal ultrasound—identifies fibroids, but imaging can’t rule out microscopic changes in the uterine lining. That’s why, before starting or changing fibroid treatments (like hormonal therapy, an IUD, or a procedure), clinicians may recommend an endometrial biopsy to ensure there isn’t an underlying endometrial problem that needs different care.^3,4,5

When Is an Endometrial Biopsy Medically Necessary?

While individual decisions are tailored to your history and exam, professional guidance typically supports endometrial sampling for:

• Abnormal uterine bleeding, especially age 45 and older
• Younger patients with risk factors for unopposed estrogen exposure (for example, obesity or polycystic ovary syndrome), persistent bleeding, or bleeding that doesn’t improve with standard treatments
• Postmenopausal bleeding
• Suspicion for endometrial hyperplasia or cancer

These indications are reflected in widely used clinical references and patient education from organizations like ACOG and HHS’s Office on Women’s Health.^4,5

Does Insurance Cover an Endometrial Biopsy?

In most plans, yes—when the procedure is medically necessary and ordered by your clinician for evaluation of symptoms like abnormal or heavy bleeding, postmenopausal bleeding, or to assess risk for endometrial disease. Coverage depends on your specific plan, network status, and where the biopsy is performed.

Key insurance factors:

• Medical necessity: Coverage is strongest when the biopsy is tied to a clear clinical reason (e.g., abnormal bleeding, risk factors).
• Site of care: An office-based biopsy is usually less expensive than one done in a hospital outpatient setting.
• Network status: In-network clinicians, facilities, and the pathology lab processing the sample typically reduce your out-of-pocket costs.
• Benefit design: Deductibles, copays, and coinsurance apply. With high-deductible plans, you may pay more up front until you meet your deductible.
• Prior authorization: Some plans require prior authorization or a referral; others do not for minor in-office procedures. Your practice can help verify.

Medicare and Medicaid

• Medicare: Part B generally covers medically necessary diagnostic procedures and pathology services ordered by your doctor. After the Part B deductible, you typically pay 20% coinsurance for the allowed amount; hospital outpatient settings may involve an additional copayment.⁶
• Medicaid: Coverage is state-specific but commonly includes medically necessary gynecologic diagnostic procedures. Check your state Medicaid plan or managed care plan for details.

Common Billing Codes and Why They Matter

While patients don’t need to memorize billing codes, having them can help when calling your insurer for a cost estimate:

• CPT 58100: Endometrial biopsy, without cervical dilation (common office code)
• CPT 58110: Add-on for endocervical curettage when performed
• CPT 88305: Surgical pathology, tissue exam (the lab/pathology charge)

Your diagnosis code(s) (ICD-10) tie the procedure to a medical reason (for example, abnormal uterine bleeding). Insurers use both procedure and diagnosis codes to determine coverage and cost-sharing.

How Much Does an Endometrial Biopsy Cost?

Prices vary widely by region, site of care, and whether you’re insured:

• Procedure fee (office): Often a few hundred dollars
• Pathology fee (lab): Often a separate charge, sometimes a few hundred dollars
• Hospital outpatient charges: Can be higher due to facility fees

For insured patients, your out-of-pocket costs depend on your deductible, copay/coinsurance, and whether all providers (including the pathologist’s lab) are in network. Ask for an estimate that includes both the procedure and the pathology reading.

How to Verify Coverage Before Your Biopsy

1. Confirm medical necessity with your clinician. Ask why the biopsy is recommended and how it will influence your care plan.
2. Get the billing codes. Request the CPT code(s) and the likely diagnosis code(s).
3. Call your insurer with the codes. Ask about coverage, prior authorization, and your estimated out-of-pocket cost. Note whether your deductible applies.
4. Verify all providers are in network. This includes the clinician, the clinic or facility, and the pathology lab that will read the sample.
5. Request a written estimate. Many clinics can provide a good-faith estimate upon request.

What to Expect During and After the Procedure

Endometrial biopsy is usually done in the office and takes a few minutes. You may feel cramping when the sample is taken. Over-the-counter pain relievers (if safe for you) can help with discomfort. Light spotting is common for a day or two. Serious complications are uncommon but can include heavy bleeding, infection, or rarely uterine perforation. Your clinician will tell you when to seek care.

Results typically return in a few days to two weeks, depending on the lab. The report helps guide next steps—whether that’s treating fibroid-related bleeding, adjusting medications, placing a hormonal IUD, or considering procedures such as hysteroscopy, myomectomy, or uterine artery embolization.

Alternatives and Complementary Tests

Depending on your symptoms and risk factors, your clinician may also recommend:

• Transvaginal ultrasound to assess fibroids and endometrial thickness
• Saline infusion sonohysterography to better visualize the uterine cavity
• Hysteroscopy (a camera exam of the uterus) with directed sampling

These tests can complement a biopsy by identifying structural causes of bleeding (like fibroids or polyps), while the biopsy evaluates the endometrial cells themselves.

Bottom Line

Endometrial biopsy is often covered by insurance when medically necessary and is commonly used alongside imaging to safely evaluate bleeding symptoms in people with fibroids. To avoid billing surprises, confirm medical necessity, check network status for both the procedure and the pathology lab, and ask your insurer for an estimate using the specific billing codes. Most importantly, use the biopsy results with your clinician to choose the safest, most effective plan for managing fibroid-related symptoms.

References

1. MedlinePlus. Endometrial biopsy. https://medlineplus.gov/ency/article/003916.htm
2. National Cancer Institute. Endometrial Cancer (Uterine Cancer) Treatment (PDQ) – Patient Version: Diagnosis and Staging. https://www.cancer.gov/types/uterine/patient/endometrial-treatment-pdq
3. Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Uterine Fibroids. https://www.nichd.nih.gov/health/topics/uterine
4. American College of Obstetricians and Gynecologists (ACOG). Abnormal Uterine Bleeding. https://www.acog.org/womens-health/faqs/abnormal-uterine-bleeding
5. Office on Women’s Health, U.S. Department of Health & Human Services. Abnormal Uterine Bleeding. https://www.womenshealth.gov/menstrual-cycle/abnormal-uterine-bleeding
6. Medicare.gov. Surgery. https://www.medicare.gov/coverage/surgery