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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHealthy Blue Louisiana Hysterectomy Policy | OpenP…
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    CurrentHealthy Blue LouisianaPolicy G-06164

    Hysterectomy Reimbursement Policy

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    This policy governs reimbursement for hysterectomy procedures for Healthy Blue Louisiana Medicaid members, including medical necessity, informed-consent documentation, nonreimbursable circumstances, and billing requirements.

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyHysterectomy Reimbursement Policy
    Policy CodePolicy G-06164
    Change TypeNo material change
    Effective DateJun 8, 2026
    Last ReviewJun 8, 2026
    Next Review DateNot specified
    Key ActionSubmit a valid, properly executed and signed Consent/Acknowledgment of Hysterectomy form with hysterectomy claims unless a documented exception applies.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Required signatures
    3Consent-form exceptions
    3Nonreimbursable purposes
    2026-06-08Approval and effective date

    Hysterectomy Reimbursement Criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Hysterectomy reimbursement criteria and exclusions

    Reimbursement is considered only when ALL of the following requirements are met:

    ALL of the following

    • Medical necessity and informed consent

      • The hysterectomy is medically necessary to treat an illness or injury.

      • ALL of the following

        • The member or authorized representative has given informed consent.
        • The member or authorized representative is fully aware that the hysterectomy will permanently prevent reproduction and has expressed this understanding verbally and in writing.

    • Consent documentation or documented exception

      • A state-approved Consent/Acknowledgment of Hysterectomy form is signed and dated by the member or applicable representative, the person obtaining consent, and the physician performing the hysterectomy.

        The form is required regardless of the member's diagnosis or age.

      • ONE of the following provider certifications is documented

        • The provider certifies in writing that the member was already sterile before the hysterectomy.
        • The provider certifies in writing that the hysterectomy was required because of a life-threatening emergency situation.
        • The provider certifies in writing that the individual was informed that the hysterectomy would permanently prevent reproduction after the individual was retroactively certified for Medicaid benefits.

    • No excluded purpose applies

      • The hysterectomy is not performed for the sole purpose of rendering the member permanently incapable of reproduction.
      • If there is more than one reason for the hysterectomy, rendering the member permanently incapable of reproduction is not the primary reason.
      • The hysterectomy is not performed for the purpose of cancer prophylaxis.

    Standard Correct Coding

    Standard correct codingmixed
    No codes listed

    Documentation and Billing Requirements

    Documentation Required

    Submit a Valid Hysterectomy Consent Form

    Obtain and submit a valid, properly executed, state-approved Consent/Acknowledgment of Hysterectomy form for professional and/or facility claims. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and receipt of the required form; claims submitted without a valid form may not be reimbursed.

    • The form is required regardless of the member’s diagnosis or age.
    • Include all required signatures: the member, except as noted; the person obtaining the member’s consent; and the physician performing the hysterectomy.
    Documentation Required

    Document Medical Necessity and Informed Consent

    Document that the hysterectomy is medically necessary to treat an illness or injury and that the member gave informed consent. The member or authorized representative must understand and acknowledge, both verbally and in writing, that the hysterectomy will render the member permanently incapable of reproducing.

    • Record the clinical rationale supporting medical necessity.
    • Document consent from the member or authorized representative and the required acknowledgment of permanent incapacity to reproduce.
    Denial Risk

    Document Any Consent-Form Exception

    A consent form is not required only when a qualifying exception applies and the provider supplies written certification for that specific exception.

    • The member was already sterile before the hysterectomy.
    • The hysterectomy was required because of a life-threatening emergency situation.
    • The individual was informed that the hysterectomy would make her permanently incapable of reproducing when the individual was retroactively certified for Medicaid benefits.
    Billing Rule

    Apply Delivery-Related Multiple Surgery Rules

    When a hysterectomy is performed in conjunction with a delivery, apply the applicable multiple surgery billing guidelines. Refer to the Modifier 50 and 51: Multiple and Bilateral Surgery policy for billing requirements.

    • Review and apply the applicable Modifier 50 and Modifier 51 multiple-surgery rules.
    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyHysterectomy Reimbursement Policy
    Policy CodePolicy G-06164
    Change TypeNo material change
    Effective DateJun 8, 2026
    Last ReviewJun 8, 2026
    Next Review DateNot specified
    Key ActionSubmit a valid, properly executed and signed Consent/Acknowledgment of Hysterectomy form with hysterectomy claims unless a documented exception applies.
    SourceLink
    On This Page
    Hysterectomy Reimbursement CriteriaStandard Correct CodingDocumentation and Billing Requirements