CurrentHighmark Blue Cross Blue Shield WnyPolicy G-06164

Hysterectomy reimbursement

Governs reimbursement for nonelective and medically necessary hysterectomy procedures for Highmark BCBS MMC, HARP, and Child Health Plus members; specifies required consent documentation and nonreimbursable indications.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyHysterectomy reimbursement

Policy CodePolicy G-06164

Change TypeNo material change

Effective DateJul 17, 2024

Next Review Date

Key ActionSubmit claims with a valid state-approved Consent/Acknowledgement of Hysterectomy form or claims may be rejected or denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Consent form requiredvalid state-approved Consent/Acknowledgement of Hysterectomy

3Nonreimbursable indications

MMC/HARP/CHPlusPrograms covered

07/17/2024Last approval date

Reimbursement Criteria and Exclusions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Hysterectomy is medically necessary to treat an illness or injury.
The member has given informed consent and is aware the procedure will render the member permanently incapable of reproducing; this understanding is documented verbally and in writing.
The member or authorized representative has signed and dated an applicable state-approved Consent/Acknowledgement of Hysterectomy form; the form is required regardless of the member's diagnosis or age.
Emergency or pre-sterile exceptions
- If the member was already sterile before the hysterectomy: the Consent/Acknowledgement of Hysterectomy form with the physician's certification is required; the member's informed consent is not required.
- If hysterectomy was required because of a life-threatening emergency in which prior consent was not possible: the Consent/Acknowledgement of Hysterectomy form with the physician's certification is required; the member's informed consent is not required.

Claims and documentation note: Claims for professional and/or facility services for a hysterectomy submitted without a valid, properly executed Consent/Acknowledgement of Hysterectomy form (including required signatures of the member except as noted, the person obtaining consent, and the performing physician) may be rejected or denied.

Concurrent delivery: If a hysterectomy is performed in conjunction with a delivery, multiple surgery guidelines apply; see Modifiers 50 and 51: Multiple and Bilateral Surgery.

Nonreimbursable indications

Hysterectomy performed for the sole purpose of rendering the member permanently incapable of reproduction (sterilization).
Hysterectomy where there is more than one reason but the primary reason is to render the member permanently incapable of reproduction.
Hysterectomy performed for the purpose of cancer prophylaxis.

Documentation and Emergency Exceptions

Documentation Required

Documentation requirement and claims risk

Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and receipt of a valid Consent/Acknowledgement of Hysterectomy form. Claims for professional and/or facility services for a hysterectomy submitted without a valid, properly executed Consent/Acknowledgement of Hysterectomy form may be rejected or denied. The form is required regardless of the member's diagnosis or age.

Required signatures: Member (except where noted), Person obtaining the member's consent, Physician performing the hysterectomy
A valid form must show that the member (or authorized representative) was informed that the hysterectomy will render the member permanently incapable of reproducing and has expressed that understanding verbally and in writing
Reimbursement basis: applicable fee schedule or contracted/negotiated rate

Note

Emergency exception

If a hysterectomy is performed because the member was already sterile prior to the procedure or due to a life‑threatening emergency in which obtaining prior consent was not possible, the Consent/Acknowledgement of Hysterectomy form is still required with the physician's certification documenting the emergency. In these cases the member's prior informed Consent/Acknowledgement is not required.

Emergency pathway requires physician certification on the Consent/Acknowledgement form documenting that prior consent was not possible due to a life‑threatening emergency
When hysterectomy is performed in conjunction with delivery, multiple surgery guidelines and applicable modifiers (e.g., 50, 51) apply

Consent/Acknowledgement of Hysterectomy Form Requirements

Consent/Acknowledgement of Hysterectomy — key requirements

Form requirementMember or authorized representative must sign and date a state-approved Consent/Acknowledgement of Hysterectomy form; the form is required regardless of the member's diagnosis or age.

Execution and signaturesA valid form must be properly executed and include signatures from the member (except as noted), the person obtaining consent, and the physician performing the hysterectomy.

Informed consent contentMember or authorized representative must be fully aware that the hysterectomy renders permanent inability to reproduce and must express this understanding verbally and in writing.

Emergency or prior sterility exceptionIf the member was already sterile or in a life‑threatening emergency where prior consent was not possible, the Consent/Acknowledgement form plus the physician's certification are required; prior informed consent is not required.

Claims riskClaims submitted without a valid, properly executed state‑approved Consent/Acknowledgement of Hysterectomy form may be rejected or denied.