CurrentColorado Rocky Mountain Health PlansPolicy CS196OH.F

Hysterectomy (for Ohio Only) – Community Plan Medical Policy

State-specific (Ohio) medical policy governing coverage and medical necessity determination for hysterectomy procedures, referencing InterQual CP criteria and Ohio Administrative Code for determinations; includes applicable CPT procedure codes, documentation requirements, and clinical evidence summaries (BRCA, chronic pelvic pain, tamoxifen).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHysterectomy (for Ohio Only) – Community Plan Medical Policy

Policy CodePolicy CS196OH.F

Change TypeDocumentation requirements added; references updated

Effective DateMar 1, 2026

Next Review Date

Key ActionProviders must document relevant medical history, physical exam, and results of diagnostic tests in the medical record; documentation must be legible, retained, and made available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews language added clarifying documentation expectations and that documentation may be required to assess clinical criteria but does not guarantee coverage.

Clinical Evidence and References sections updated to reflect most current information.

1State-specific policy (Ohio only)

BRCA1/BRCA2Explicit covered indication listed

InterQualPrimary medical necessity criteria source

Coverage Summary

This is an Ohio-specific medical policy (Policy Number: CS196OH.F) for Hysterectomy that governs coverage and medical necessity determinations for hysterectomy procedures (abdominal, vaginal, laparoscopic, robotic) and related procedures. The policy uses InterQual® CP criteria as the primary clinical coverage source and defers to the Ohio Administrative Code where applicable.

Key metadata

Policy numberCS196OH.F

Effective date2026-03-01

Last review date2026-03-01

Primary medical necessity sourceInterQual® CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy

Scope / state noteState-specific policy applicable to Ohio; medical necessity also evaluated using Ohio Administrative Code (e.g., Rule 5160-1-01) when services are unproven or limited

Coverage follows InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy and Ohio Administrative Code when applicable.

Medical Necessity / Coverage Criteria

Coverage follows InterQual® CP and Ohio Administrative Code when applicable.

ALL of the following

The requested hysterectomy must meet InterQual® CP criteria for hysterectomy (+/- BSO or bilateral salpingectomy) as applicable.
For services stated as unproven or with coverage/quantity limits, medical necessity will be evaluated using Ohio Administrative Code 5160-1-01.

Prophylactic Hysterectomy for BRCA1/BRCA2

Covered when clinical rationale supports management of individuals with BRCA1 or BRCA2 gene mutation.

ANY of the following

Applicable Procedure Codes (CPT)

Applicable CPT - Abdominal hysterectomy codesCPT

58150	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
58152	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)
58180	Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

Applicable CPT - Laparoscopic hysterectomy codesCPT

58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
58542	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
58544	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Applicable CPT - Laparoscopic-assisted vaginal hysterectomy codesCPT

58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Applicable CPT - Vaginal hysterectomy codesCPT

58260	Vaginal hysterectomy, for uterus 250 g or less
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
58263	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58270	Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
58290	Vaginal hysterectomy, for uterus greater than 250 g
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58292	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
58294	Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Provider Actions & Requirements

Documentation Required

Maintain complete medical records to support medical necessity

Document and retain complete, legible medical records demonstrating the clinical rationale and findings that support medical necessity for the requested hysterectomy.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Documentation must be legible
Documentation must be maintained in the patient’s medical record
Documentation must be made available upon request

Prior Authorization

InterQual® criteria and state rule used for medical necessity determinations

Background & Evidence Summary

This policy defines hysterectomy procedures (total and supracervical; vaginal, abdominal, laparoscopic, laparoscopic-assisted, robotic) and applicable CPT procedure codes, and states these procedures are proven and medically necessary in specified circumstances. Medical necessity determinations reference InterQual® CP for hysterectomy (± BSO or bilateral salpingectomy) and, for services described as unproven or limited, will be evaluated using the Ohio Administrative Code. The policy also summarizes evidence and guidance on BRCA-associated uterine cancer risk and prophylactic hysterectomy, and reviews literature on chronic pelvic pain, adenomyosis, and alternatives such as the levonorgestrel-releasing intrauterine system (LNG-IUS).

Evidence summaries

Definitions & guidelines

Revision History

03/01/2026material_changeLatest

Added Medical Records Documentation Used for Reviews language clarifying documentation expectations and that documentation may be required to assess clinical criteria but does not guarantee coverage; specified required elements (relevant medical history, physical exam, results of pertinent diagnostic tests/procedures), legibility, retention in the patient's medical record, and availability upon request.

03/01/2026supporting_information_updatedLatest

Supporting information, Clinical Evidence and References sections updated; previous policy version CS196OH.E archived.