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

    Hysterectomy

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    Reimbursement for medically necessary, non-elective hysterectomy procedures for Healthy Blue Louisiana Dual Advantage members, subject to consent, acknowledgment, coverage, and coding requirements.

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyHysterectomy
    Policy CodePolicy G-06164
    Change TypeNo material change
    Effective Date06/08/2026
    Last ReviewJun 8, 2026
    Next Review DateNot scheduled
    Key ActionUse a properly executed, applicable state-approved Consent/Acknowledgment of Hysterectomy form with all required signatures.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3Nonreimbursable circumstances
    3Required form signatures
    100%Form requirement applicability
    06/08/2026Effective date

    Hysterectomy Reimbursement Criteria

    Policy Summary
    PayerHealthy Blue Louisiana
    PolicyHysterectomy
    Policy CodePolicy G-06164
    Change TypeNo material change
    Effective Date06/08/2026
    Last ReviewJun 8, 2026
    Next Review DateNot scheduled
    Key ActionUse a properly executed, applicable state-approved Consent/Acknowledgment of Hysterectomy form with all required signatures.
    SourceLink
    On This Page
    Hysterectomy Reimbursement CriteriaCoding RequirementsProvider Documentation and Billing Actions

    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

    Reimbursement is considered when all applicable medical necessity, consent, acknowledgment, form-execution, and indication criteria are met.

    ALL of the following

    • Medical necessity

      • The hysterectomy is non-elective and medically necessary to treat an illness or injury.

    • ONE of

      • Standard consent pathway

        • The member has given informed consent.
        • The member or authorized representative understands, both verbally and in writing, that the hysterectomy will permanently render the member incapable of reproducing.
        • The member or authorized representative has signed and dated an applicable state-approved Consent/Acknowledgment of Hysterectomy form. This requirement applies regardless of the member's diagnosis or age.
        • The properly executed form includes the required signatures of the member, except as noted, the person obtaining the member's consent, and the physician performing the hysterectomy.

      • Consent exception pathway

        • ONE of

          • The member was already sterile before the hysterectomy.
          • The hysterectomy was required because of a life-threatening emergency in which the physician determined that prior consent or acknowledgment was not possible.
        • The Consent/Acknowledgment of Hysterectomy form includes the physician's certification.
        • Member informed consent or acknowledgment is not required in these circumstances.

    • Indication exclusions

      • The hysterectomy is not performed solely to render the member permanently incapable of reproduction, and permanent sterilization is not the primary reason when multiple reasons exist.
      • The hysterectomy is not performed for the purpose of cancer prophylaxis.

    Coding Requirements

    Standard correct coding appliesmixed
    No codes listed

    Provider Documentation and Billing Actions

    Documentation Required

    Establish medical necessity

    Document that the hysterectomy is medically necessary to treat an illness or injury and is non-elective, subject to applicable member, provider, state, federal, and CMS requirements.

    Documentation Required

    Obtain informed consent

    Obtain informed consent and ensure that the member or authorized representative understands verbally and in writing that the hysterectomy will permanently eliminate the ability to reproduce.

    Documentation Required

    Complete the state-approved consent form

    Use the applicable state-approved Consent/Acknowledgment of Hysterectomy form. The form must be properly executed, signed and dated, and include the required signatures.

    • Member, except when an applicable exception applies
    • Person obtaining the member’s consent
    • Physician performing the hysterectomy
    Documentation Required

    Apply consent exceptions

    Apply the consent exceptions when the member was already sterile or a life-threatening emergency made prior consent impossible as determined by the physician. The form with the physician’s certification is still required, but the member’s informed consent or acknowledgment is not required in these circumstances.

    • Already sterile before the hysterectomy
    • Life-threatening emergency in which the physician determined that prior consent or acknowledgment was not possible
    Billing Rule

    Retain but do not routinely submit consent forms

    Retain the informed Consent/Acknowledgment of Hysterectomy documentation, but do not routinely submit it with claims. The health plan does not require these forms to accompany the claim unless otherwise required.

    Billing Rule

    Apply delivery-related multiple surgery rules

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

    Denial Risk

    Avoid nonreimbursable indications

    Expect nonreimbursement when the hysterectomy is performed solely to render the member permanently incapable of reproduction, when permanent sterilization is the primary reason among multiple indications, or when the purpose is cancer prophylaxis.