CurrentAnthemPolicy G-06164

Hysterectomy reimbursement

Defines Anthem New York Medicaid reimbursement requirements for nonelective and medically necessary hysterectomy procedures, including required consent/acknowledgement form and circumstances that are nonreimbursable; applies to covered members and providers billing Medicaid in New York.

Policy Summary

PayerAnthem

PolicyHysterectomy reimbursement

Policy CodePolicy G-06164

Change TypeReview — no material changes

Effective Date07/17/2024

Next Review Date

Key ActionRequire a valid state-approved Consent/Acknowledgement of Hysterectomy form; if performed with delivery follow multiple surgery guidelines.

SourceLink

POLICY UPDATE CHANGES

07/17/2024 review approved and effective: no changes.

G-06164policy number

07/17/2024effective / last approval date

3required signatures

1section identifier lines

Hysterectomy Coverage Criteria

Hysterectomy coverage criteria

Anthem allows reimbursement when hysterectomy is nonelective and medically necessary and all consent requirements are met. Reimbursement is not allowed in specified circumstances.

ALL of the following

Hysterectomy is medically necessary to treat an illness or injury.
The member has given informed consent.
The member or authorized representative is fully aware that the hysterectomy will render the member permanently incapable of reproducing and has verbally and in writing expressed this understanding.
The member or authorized representative has signed and dated an applicable state-approved Consent/Acknowledgement of Hysterectomy form (required regardless of diagnosis or age).

Policy Summary

PayerAnthem

PolicyHysterectomy reimbursement

Policy CodePolicy G-06164

Change TypeReview — no material changes

Effective Date07/17/2024

Next Review Date

Key ActionRequire a valid state-approved Consent/Acknowledgement of Hysterectomy form; if performed with delivery follow multiple surgery guidelines.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Exceptions for prior consent

A Consent/Acknowledgement of Hysterectomy form with the physician's certification is required.
The member's prior informed Consent/Acknowledgement of Hysterectomy is not required.

ALL of the following

A valid Consent/Acknowledgement of Hysterectomy form must be properly executed and include signatures from: the member (except as noted), the person obtaining consent, and the physician performing the hysterectomy.
If performed in conjunction with delivery, multiple surgery guidelines apply (see Modifiers 50 and 51).

Not reimbursed (any of the following)

The hysterectomy is performed for the sole purpose of rendering the member permanently incapable of reproduction.
There is more than one reason for the hysterectomy, but the primary reason is to render the member permanently incapable of reproduction.
The hysterectomy is performed for the purpose of cancer prophylaxis.

ALL of the following

Claims submitted without a valid informed Consent/Acknowledgement of Hysterectomy form may be rejected, denied, recovered, or adjusted.

ALL of the following

Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and receipt of a valid Consent/Acknowledgement of Hysterectomy form.

ALL of the following

Applies to nonelective and medically necessary hysterectomy procedures for covered members unless provider, state, federal, or CMS contracts/requirements indicate otherwise.

ALL of the following

A valid Consent/Acknowledgement of Hysterectomy form must include signatures from: member (except as noted), person obtaining consent, and the physician performing the hysterectomy.

ALL of the following

If member was already sterile before hysterectomy or if hysterectomy was life‑threatening emergency where prior consent was not possible, physician certification on the Consent/Acknowledgement form is required and prior informed consent is not required.

ALL of the following

When performed with delivery, follow multiple surgery guidelines (Modifiers 50 and 51: Multiple and Bilateral Surgery).

ALL of the following

Claims for professional and/or facility services submitted without a valid informed Consent/Acknowledgement of Hysterectomy form may be rejected or denied.

ALL of the following

Anthem considers reimbursement only when the above medical necessity and consent criteria are met.

ALL of the following

This policy aligns with applicable state and federal requirements and references state‑approved Consent/Acknowledgement of Hysterectomy forms.

ALL of the following

Ensure the Consent/Acknowledgement form is included with claims as required to support reimbursement eligibility.

ALL of the following

Not reimbursed if performed for sole purpose of permanent infertility, if primary reason is to render member infertile, or for cancer prophylaxis.

ALL of the following

Providers should follow authorization and medical necessity guidelines appropriate to the procedure and member's state of residence; improper coding may result in claim rejection, denial, recovery, or adjustment.

ALL of the following

Required signatures on the Consent/Acknowledgement form: member (except as noted), person obtaining consent, and the physician performing the hysterectomy (three signatures).

Coding and Consent Requirements

Standard correct codingmixed

Bill with CPT, HCPCS, and/or revenue codes supported by medical record

Consent form requirement

Consent form requirementA valid, state-approved Consent/Acknowledgement of Hysterectomy form is required for reimbursement except when the member was already sterile before hysterectomy or the hysterectomy was a life‑threatening emergency where prior consent was not possible (in those cases a Consent/Acknowledgement form with physician certification is required).

Required signaturesThe valid Consent/Acknowledgement form must be properly executed and include signatures from: the member (except as noted), the person obtaining the member's consent, and the physician performing the hysterectomy.

Effect of missing formClaims for professional and/or facility services submitted without a valid informed Consent/Acknowledgement of Hysterectomy form may be rejected or denied.

Form applicabilityThe state‑approved Consent/Acknowledgement of Hysterectomy form is required regardless of the member's diagnosis or age.

When prior informed consent not requiredIf prior informed consent was not possible due to a life‑threatening emergency, the physician's certification on the Consent/Acknowledgement form substitutes for prior informed consent.

Provider Billing, Authorization, and Documentation Requirements

Documentation Required

Consent/Acknowledgement Form Required

Anthem requires a valid, properly executed Consent/Acknowledgement of Hysterectomy form on file for reimbursement of nonelective, medically necessary hysterectomy procedures. The form must include signatures of the member (unless exception applies), the person obtaining consent, and the physician performing the hysterectomy. If the member was already sterile before the hysterectomy or the procedure was performed emergently when prior consent was not possible, include the Consent/Acknowledgement form with the physician’s certification documenting the circumstances.

A valid state-approved Consent/Acknowledgement of Hysterectomy form is required regardless of member age or diagnosis.
If consent could not be obtained due to a life‑threatening emergency, include the form plus the physician’s certification explaining why prior consent was not possible.
Claims submitted without a valid Consent/Acknowledgement form may be rejected, denied, or recouped.

Billing Rule

Multiple‑Surgery and Billing Guidance

When a hysterectomy is performed in conjunction with a delivery, follow Anthem’s multiple-surgery billing guidance. Providers must bill in accordance with applicable multiple and bilateral surgery modifier rules and the Modifiers 50 and 51: Multiple and Bilateral Surgery policy. Ensure documentation supports medical necessity for each procedure and include the required Consent/Acknowledgement form to avoid claim denials.

Apply appropriate modifiers (e.g., Modifier 50, Modifier 51) per Anthem policy and coding guidelines.
Document distinct medical necessity for the hysterectomy and for the delivery when both are performed.
Include the Consent/Acknowledgement form with the claim when hysterectomy is performed with delivery to prevent denial or recoupment.

Referenced Definitions

General Reimbursement Policy Definitions

Referenced definitionsGeneral Reimbursement Policy Definitions (see policy definitions section).

PurposeProvide standard terms and definitions used across Anthem reimbursement policies to support consistent claims processing and interpretation.

ScopeApplies to Anthem New York Medicaid reimbursement policies cited by this document.

LocationDefinitions are listed under the policy 'Definitions' heading; consult the referenced general reimbursement definitions for term-specific language.