CurrentAnthemPolicy G-06164

Hysterectomy, Reimbursement Policy

This policy governs Anthem Medicare Advantage reimbursement for nonelective and medically necessary hysterectomy procedures and outlines required consent documentation and situations that are nonreimbursable. It affects providers submitting claims for Anthem Medicare Advantage members.

Policy Summary

PayerAnthem

PolicyHysterectomy, Reimbursement Policy

Policy CodePolicy G-06164

Change TypeNo material change

Effective DateJun 29, 2022

Next Review Date

Key ActionFollow authorization and medical necessity guidelines and document informed consent with a signed Consent/Acknowledgement of Hysterectomy Form when performing nonelective, medically necessary hysterectomy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Consent form always requiredConsent form always required

Nonelective & medically necessaryReimbursement limited to nonelective/medically necessary

Three required signaturesRequired signatures

3Nonreimbursable reasons listed

Biennial reviewsPolicy history

Coverage Criteria and Exclusions

Coverage criteria and exclusions

Anthem Medicare Advantage reimburses hysterectomy only when medically necessary and required consent criteria are met; specific nonreimbursable circumstances are listed.

Covered when ALL of the following are met:

The 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 orally and in writing expressed this understanding.
The member or authorized representative has signed and dated an applicable Consent/Acknowledgement of Hysterectomy Form. The form is required regardless of the member's diagnosis or age.

Policy Summary

PayerAnthem

PolicyHysterectomy, Reimbursement Policy

Policy CodePolicy G-06164

Change TypeNo material change

Effective DateJun 29, 2022

Next Review Date

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.

Authorization and Documentation Requirements

Prior Authorization

Authorization and necessity — Reimbursement allowed for nonelective, medically necessary hysterectomy when criteria met; follow authorization and medical necessity guidelines and document consent/signatures.

Anthem Medicare Advantage allows reimbursement for nonelective, medically necessary hysterectomy procedures for covered members when authorization and medical necessity requirements are met. Providers must follow authorization and medical necessity guidelines and ensure the medical record documents informed consent and required signatures. A properly executed Consent/Acknowledgement of Hysterectomy Form must be completed and include the member (unless exempt), the person obtaining consent, and the physician performing the hysterectomy. If the member was sterile prior to the hysterectomy or the procedure was performed emergently when prior consent was not possible, the physician’s certification and the Consent/Acknowledgement of Hysterectomy Form are still required; however, informed consent/acknowledgement is not required in those emergency situations. Anthem Medicare Advantage does not require the Consent/Acknowledgement of Hysterectomy Form to be submitted with claims. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and is subject to provider, state, federal, or CMS contracts and requirements.

Consent/Acknowledgement of Hysterectomy Form required and must be signed by: Member (unless exempt); Person obtaining consent; Physician performing hysterectomy.
If member was sterile before surgery or hysterectomy was due to life‑threatening emergency and prior consent was not possible: physician certification plus the form required; prior informed consent not required.
Do not submit the Consent/Acknowledgement form with claims.
Reimbursement allowed only for nonelective, medically necessary hysterectomy and per applicable fee schedule/contracted rate.

Definitions

Definitions — general reimbursement policy definitions

Purpose of policiesServe as a guide to assist in accurate claims submissions and outline the basis for reimbursement by Anthem Medicare Advantage when the service is covered by a member's benefit plan.

Coverage vs. ReimbursementA determination that a service is covered under a member's benefit plan is not a determination that you will be reimbursed; services must also meet authorization and medical necessity guidelines.

Coding requirementsProviders must use industry-standard, compliant codes (CPT, HCPCS, revenue) on all claim submissions; billed codes must be fully supported in the medical record or office notes.

Authorization and medical necessityServices must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Claim consequencesIf coding/billing guidelines or current reimbursement policies are not followed, Anthem Medicare Advantage may reject/deny the claim, recover/recoup payment, or adjust reimbursement.

Policy updates and precedencePolicies are developed based on nationally accepted standards and may be superseded by provider, state, federal, or CMS mandates; Anthem may review and revise policies periodically.

OpenPayer

Hysterectomy, Reimbursement Policy

Coverage Criteria and Exclusions

Coding Requirements

Authorization and Documentation Requirements

Definitions