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CurrentCurativePolicy CHP-IP-2026-137

F010. Myomectomy (Abdominal and Complex Laparoscopic)

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Inpatient medical-necessity criteria, level of care, continued stay, discharge readiness, documentation, and coding for abdominal and complex laparoscopic or robotic myomectomy in members seeking uterine preservation or future fertility.

Policy Summary

PayerCurative

PolicyF010. Myomectomy (Abdominal and Complex Laparoscopic)

Policy CodePolicy CHP-IP-2026-137

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument symptomatic leiomyomas, uterine or fertility preservation goals, medical-management disposition, malignancy-risk assessment, and at least one indication requiring inpatient care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥16 weeksUterine size threshold

≥4Myomas removed threshold

≥10 cmMyoma size threshold

≥1,000 mLEstimated blood-loss threshold

24 hoursContinued-stay review

1–3 daysOpen myomectomy stay

Inpatient Medical Necessity and Level of Care

Initial inpatient medical necessity

Inpatient admission is medically necessary when ALL of the following are met.

Procedure indications met

Symptomatic leiomyomas confirmed by imaging: Heavy menstrual bleeding with anemia (hemoglobin below 12 g/dL) or transfusion; bulk symptoms including pelvic pressure, urinary frequency, or hydronephrosis; or infertility or recurrent pregnancy loss with cavity-distorting or large myomas.
Uterine or fertility preservation: The patient desires to preserve the uterus or fertility.
Medical management disposition: Medical management was considered and was ineffective, not tolerated, contraindicated, or declined after counseling.

Policy Summary

PayerCurative

PolicyF010. Myomectomy (Abdominal and Complex Laparoscopic)

Policy CodePolicy CHP-IP-2026-137

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument symptomatic leiomyomas, uterine or fertility preservation goals, medical-management disposition, malignancy-risk assessment, and at least one indication requiring inpatient care.

SourceLink

On This Page

Malignancy-risk assessment: Pre-operative assessment for malignancy risk is appropriate to age and imaging, with endometrial sampling when indicated.

Inpatient setting required

Open abdominal approach: Open abdominal myomectomy (laparotomy).
Complex laparoscopic or robotic procedure: Laparoscopic or robotic myomectomy with uterine size of 16 weeks or more, 4 or more myomas removed, or a myoma 10 cm or larger.16 weeks or more; 4 or more myomas; or 10 cm or larger
Blood loss or anemia: Estimated blood loss of 1,000 mL or more, intraoperative transfusion, or post-operative hemoglobin below 7 g/dL or symptomatic anemia.Estimated blood loss >= 1,000 mL; post-operative hemoglobin < 7 g/dL
Complication or conversion: Intraoperative bowel, bladder, ureteral, or vascular injury, or conversion to laparotomy.
Higher-risk recovery needs: ASA physical status III to IV, or obstructive sleep apnea needing monitored recovery.ASA III-IV
Uncontrolled post-operative symptoms: Pain, nausea, or urinary retention is not controlled within the observation period.Observation period up to 24-48 hours

Observation or outpatient instead of inpatient

Outpatient surgery or observation up to 24 to 48 hours is appropriate when ANY of the following applies and no inpatient criterion is met.

Outpatient or observation pathway: Hysteroscopic myomectomy; uncomplicated laparoscopic or robotic myomectomy without the stated size, number, or blood-loss thresholds; or recovery on an enhanced recovery pathway meeting discharge criteria within 24 hours.Up to 24 to 48 hours

No inpatient criterion may be met.

Intensive care unit level

ICU care is appropriate when ANY of the following is present.

ICU-level condition: Hemorrhagic shock or massive transfusion; or respiratory failure or need for vasopressors.

Step-down or intermediate care

Step-down care is appropriate when ANY of the following is present and ICU criteria are not met.

Intermediate-care condition: Ongoing transfusion with hemodynamic monitoring; or obstructive sleep apnea with opioid needs requiring continuous oximetry.

ICU criteria must not be met.

Medical-surgical unit level

A medical-surgical bed is appropriate when ANY of the following applies and higher-level criteria are not met.

Medical-surgical level condition: Routine recovery after open myomectomy; or need for IV analgesia, IV fluids, or IV iron or transfusion for anemia with stable vital signs.

Higher-level criteria must not be met.

Discharge readiness

Discharge is appropriate when ALL of the following are met.

Discharge readiness: Vital signs are stable and hemoglobin is stable without symptoms; pain is controlled on oral medicines; the patient is tolerating diet, voiding, and ambulating; there are no signs of infection or bowel dysfunction; and follow-up is arranged within 2 weeks with counseling on interpregnancy interval and delivery planning after myomectomy.Follow-up within 2 weeks

All discharge conditions must be met.

Continued stay

Continued stay is medically necessary, with review every 24 hours, when ANY of the following is documented.

Continued-stay condition: Bleeding or symptomatic anemia needing transfusion; ileus needing NPO status or IV fluids; infection or abscess needing IV antibiotics or drainage; or urinary tract or bowel injury under management.Review every 24 hours

Does not meet criteria

The following circumstances do not meet this policy's medical-necessity criteria and require physician review.

Does not meet criteria: Inpatient admission for hysteroscopic or uncomplicated laparoscopic myomectomy; myomectomy for asymptomatic leiomyomas without an infertility indication; or pre-operative admission without a medical need.

The request is referred for physician review and is not denied by an automated system or non-physician reviewer.

Determination authority

Utilization review and determination rules.

Determination authority and review rules: Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination. Requests that do not meet criteria are referred for physician review; only a licensed physician of the same or similar specialty may issue an adverse determination after offering the requesting provider a peer-to-peer discussion. If the requested quantity, units, or duration exceed documentation support, the supported portion is approved and only the unsupported increment is reviewed.

The absence of a criterion addressing a service is not itself a basis for an adverse determination; the request is reviewed by a physician applying generally accepted standards of medical practice.

Concurrent review and inpatient status

Concurrent review rules.

Concurrent review applies to each continued-stay period. Days already authorized are not retroactively denied, and an expected length of stay is a planning benchmark rather than a limit on covered days.

The Medicare two-midnight benchmark is not a coverage criterion for these commercial plans. Coverage remains subject to the member's benefit plan and applicable federal and state law.

Hysteroscopic myomectomy and uncomplicated laparoscopic myomectomy are ordinarily outpatient services rather than inpatient admissions. Observation may be appropriate when needed for short-term recovery, provided no inpatient medical-necessity criterion is met.

A rapidly growing uterine mass, growth after menopause, or imaging suspicious for sarcoma requires gynecologic oncology evaluation before proceeding. Uncontained power morcellation should be avoided.

Inpatient admission for hysteroscopic or uncomplicated laparoscopic myomectomy does not meet inpatient medical-necessity criteria because outpatient surgery or observation meets the need. Such requests are referred for physician review.

Myomectomy for asymptomatic leiomyomas without an infertility indication does not meet medical-necessity criteria because no symptom benefit is expected. The request is referred for physician review.

A pre-operative admission without a medical need does not meet medical-necessity criteria. Pre-operative preparation should be performed in the outpatient setting; requests are referred for physician review.

Applicable Diagnosis, Procedure, and Facility Codes

ICD-10-CM uterine leiomyomaICD-10

D25.0	Uterine leiomyoma
D25.1	Uterine leiomyoma
D25.2	Uterine leiomyoma
D25.9	Uterine leiomyoma

ICD-10-PCS excision of uterusICD-10

0UB90ZZ	Excision of uterus (open)
0UB94ZZ	Excision of uterus (percutaneous endoscopic)

CPT myomectomyCPT

58140	Abdominal, vaginal, and laparoscopic myomectomy
58145	Abdominal, vaginal, and laparoscopic myomectomy
58146	Abdominal, vaginal, and laparoscopic myomectomy
58545	Abdominal, vaginal, and laparoscopic myomectomy
58546	Abdominal, vaginal, and laparoscopic myomectomy

MS-DRG FY2027 v44mixed

742	Uterine and adnexa procedures for nonmalignancy with CC/MCC
743	Uterine and adnexa procedures for nonmalignancy without CC/MCC

Facility revenue codesRevenue

0110	Room and board
0111	Room and board
0112	Room and board
0113	Room and board
0114	Room and board
0115	Room and board
0116	Room and board
0117	Room and board
0118	Room and board
0119	Room and board

1–10 of 35

1/4

Uterine size threshold

Inpatient thresholdUterine size of 16 weeks or more

Applicable procedureLaparoscopic or robotic myomectomy

Coverage contextSupports an inpatient setting when the required procedure indications are also met

Number of myomas removed

Inpatient threshold4 or more myomas removed

Applicable procedureLaparoscopic or robotic myomectomy

Coverage contextSupports an inpatient setting when the required procedure indications are also met

Individual myoma size

Inpatient thresholdIndividual myoma 10 cm or larger

Applicable procedureLaparoscopic or robotic myomectomy

Coverage contextSupports an inpatient setting when the required procedure indications are also met

Estimated blood loss

Inpatient thresholdEstimated blood loss of 1,000 mL or more

Related indicationIntraoperative transfusion also supports an inpatient setting

Applicable approachApplies as an inpatient-setting indication for myomectomy when required procedure indications are met

Hemoglobin thresholds

Heavy menstrual bleeding with anemiaHemoglobin below 12 g/dL

Postoperative anemiaHemoglobin below 7 g/dL supports inpatient care

Symptomatic anemiaSymptomatic anemia supports inpatient care

Observation period

Observation or outpatient periodUp to 24 to 48 hours

Enhanced recovery pathwayRecovery meeting discharge criteria within 24 hours supports outpatient management or observation

Escalation to inpatient carePain, nausea, or urinary retention not controlled within the observation period supports inpatient care

Documentation, Authorization, and Review Actions

Documentation Required

Meet Inpatient Medical-Necessity Criteria

An inpatient admission for myomectomy is medically necessary only when the procedure indications and an inpatient-setting requirement are both documented. The record must establish symptomatic, imaging-confirmed leiomyomas, a goal of uterine or fertility preservation, appropriate malignancy-risk assessment, and medical management that was considered and found ineffective, not tolerated, contraindicated, or declined after counseling.

Procedure indications: Symptomatic leiomyomas with heavy menstrual bleeding and hemoglobin below 12 g/dL or transfusion; bulk symptoms such as pelvic pressure, urinary frequency, or hydronephrosis; or infertility/recurrent pregnancy loss associated with cavity-distorting or large myomas.
Inpatient setting: Open abdominal myomectomy; laparoscopic or robotic myomectomy with uterine size ≥16 weeks, at least 4 myomas removed, or a myoma ≥10 cm; estimated blood loss ≥1,000 mL, intraoperative transfusion, postoperative hemoglobin <7 g/dL, or symptomatic anemia; intraoperative bowel, bladder, ureteral, or vascular injury or conversion to laparotomy; ASA III–IV or obstructive sleep apnea requiring monitored recovery; or pain, nausea, or urinary retention uncontrolled during observation.

Step Therapy

Medical Therapy Is Not a Mandatory Step

Prior medical therapy is not a mandatory step before myomectomy. It need only be considered and documented as ineffective, not tolerated, contraindicated, or declined after counseling; surgery may be selected when medical therapy is not desired or otherwise unsuitable.

Document the relevant prior, attempted, declined, contraindicated, or unsuitable medical-management history.
Failure of medical therapy is not required when it is ineffective, contraindicated, not tolerated, or not desired.

Documentation Required

Required Clinical and Operative Documentation

Include complete clinical and operative documentation with the request and medical record so the indication, complexity, and inpatient need can be evaluated.

Imaging identifying myoma number, size, location, and uterine size.
Symptoms and hemoglobin, including anemia or transfusion history when applicable.
Fertility goals and the desire to preserve the uterus or future fertility.
Prior, declined, contraindicated, ineffective, or otherwise unsuitable medical therapy.
Operative report documenting the approach, blood loss, and complications.
Pre-operative malignancy-risk assessment appropriate to age and imaging, including endometrial sampling when indicated.

Billing Rule

Support the Requested Amount

The documentation must support the requested quantity, units, and duration. When only part of a request is supported, the supported portion may be approved and only the unsupported increment is subject to review.

Specify and substantiate the requested quantity, units, and duration.
Do not assume an unsupported amount requires denial of the entire request; supported portions may be approved.

Denial Risk

Lower-Acuity Procedure Submitted as Inpatient

Submit hysteroscopic and uncomplicated laparoscopic myomectomy cases at the lower appropriate level of care unless documentation establishes a qualifying inpatient need. Outpatient or observation care generally meets the need for these procedures.

Inpatient admission for hysteroscopic myomectomy does not meet criteria when outpatient or observation care is appropriate.
Inpatient admission for an uncomplicated laparoscopic myomectomy does not meet criteria when outpatient or observation care is appropriate.

Denial Risk

Asymptomatic Leiomyomas Without Infertility Indication

Myomectomy for asymptomatic leiomyomas without an infertility indication does not meet medical-necessity criteria because no symptom benefit is expected. Such requests are referred for physician review rather than automatically denied by a non-physician reviewer or automated system.

Document symptoms or an infertility indication when requesting myomectomy for leiomyomas.
Absence of symptoms and infertility indication creates denial risk.

Denial Risk

Unnecessary Pre-Operative Admission

Pre-operative preparation should occur in the outpatient setting unless a specific medical need for admission before surgery is documented. A pre-operative admission without medical need does not meet criteria and is referred for physician review.

Document the clinical reason pre-operative admission is necessary rather than performing routine preparation as an inpatient.
Routine pre-operative preparation is outpatient.

Note

Physician Review and Peer-to-Peer Process

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may not issue an adverse determination. Requests that do not meet criteria, including unsupported increments, must be referred for physician review.

Only a licensed physician of the same or similar specialty may issue an adverse determination after offering the requesting provider a peer-to-peer discussion.
The reviewing physician must meet applicable licensure, specialty, and medical-director requirements for the plan's situs state.
Concurrent review applies to each continued-stay period; already authorized days are not retroactively denied, and expected length of stay is a planning benchmark rather than a limit on covered days.
The Medicare two-midnight benchmark is not a coverage criterion for these commercial plans, and the procedure need not appear on the CMS inpatient-only list.
The absence of a stated criterion is not itself a basis for an adverse determination; a physician applies generally accepted standards of medical practice.

Condition and Clinical Context

Uterine leiomyomas are benign uterine tumors that may cause heavy menstrual bleeding, anemia, pelvic pressure, urinary symptoms, infertility, or recurrent pregnancy loss. Myomectomy provides a surgical option for patients who desire uterine preservation or future fertility. Open myomectomy for large or numerous myomas carries greater blood-loss and transfusion risk and commonly requires a short inpatient stay, while uncomplicated laparoscopic myomectomy is usually outpatient or requires only short observation.

Policy Definitions

Enhanced recovery pathway

ProtocolStandardized perioperative protocol

Core componentsPre-operative counseling, multimodal analgesia, early feeding, and mobilization

PurposeShortens recovery