Attachment A - AHCCCS Hysterectomy Consent and Acknowledgement Form
This attachment documents required informed consent for hysterectomy and the payer's coverage restriction that hysterectomy for the sole purpose of sterilization is not covered; it applies to AHCCCS members whose procedures seek reimbursement under the payer.
No material clinical or coverage changes in this revision.
Coverage Criteria
AHCCCS coverage exclusions for hysterectomy
Not covered when ANY of the following apply
See AHCCCS policy statement on exclusions.
See AHCCCS policy statement on exclusions.
AHCCCS does not cover hysterectomy procedures when they are performed solely for the purpose of rendering an individual permanently incapable of reproducing. This exclusion also applies when the sterilization purpose is the but-for reason for the procedure — that is, if there were multiple stated purposes but the procedure would not have been performed but for the intent to render the individual permanently incapable of reproducing, the procedure is not covered. Providers should ensure documentation clearly demonstrates medically necessary indications distinct from sterilization if reimbursement is sought.
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