CurrentPremera BluecrossPolicy N/A

Hysterectomy for Non-Malignant Conditions

Clinical background, definitions, indications, procedural types and routes for hysterectomy and related pelvic surgery; intended for clinicians making treatment and coverage decisions for Premera members. This part of the document provides definitions, staging, and literature references relevant to hysterectomy decision-making.

Policy Summary

PayerPremera Bluecross

PolicyHysterectomy for Non-Malignant Conditions

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDocument diagnostic evaluation and attempted alternative therapies before elective hysterectomy (except in life-threatening emergencies).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-03-01Most recent annual review approval date

60%Proportion for leiomyomata

14% | 64% | 22%Route distribution

90-dayProvider notification hold

non-Medicare AdvantageApplies to plans

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Coverage criteria and medical necessity

Indications and Procedural Criteria

Covered when supported by clinical indications and after adequate diagnostic evaluation and consideration/trial of less invasive alternative therapies (except in life‑threatening emergencies).

General coverage conditions: Hysterectomy may be indicated for conditions including abnormal or dysfunctional uterine bleeding; cancer; chronic pelvic pain or infection (e.g., endometriosis, pelvic inflammatory disease) not relieved by conservative treatment; complications related to childbirth (e.g., uterine rupture, intractable postpartum hemorrhage); gynecologic cancer prevention; premalignant disease of the uterus, cervix, ovaries, fallopian tubes or endometrium; symptomatic pelvic organ prolapse; symptomatic uterine leiomyomata (fibroids); and tubo-ovarian abscess.

List is not exhaustive; choose indication based on clinical judgment and documentation.

Procedure type selection: Select procedure extent (radical, subtotal, total) based on diagnosis, disease extent, and clinical need.

Radical hysterectomy involves removal of uterus, cervix, adnexa and regional lymphatics; subtotal preserves the cervix; total removes uterus and cervix (bilateral salpingo-oophorectomy may be performed when indicated).

Route selection: Choose surgical route (abdominal, laparoscopic, vaginal) based on indication, uterine size, patient factors and surgeon skill.

Abdominal, laparoscopic, and vaginal approaches are acceptable when selected appropriately; less invasive approaches may be preferred when clinically appropriate.

Preoperative evaluation and alternatives: For non-emergent, non-oncologic indications, documentation must show adequate diagnostic evaluation and that appropriate less invasive alternative therapies were considered and attempted when reasonable.

Absence of adequate evaluation or failure to try alternatives were the most common reasons recommendations were judged inappropriate in cited studies; emergency situations (e.g., uterine hemorrhage) are exceptions.

Hysterectomy for non-emergent indications should not be performed without adequate diagnostic evaluation and consideration of less invasive alternatives. The literature cited found that the most common reasons recommendations for hysterectomy were judged inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy; the authors concluded that, except in life‑threatening emergencies (e.g., uterine hemorrhage), clinicians and patients should ensure a proper diagnostic evaluation and consideration of alternatives (and the patient’s child‑bearing plans) prior to recommending hysterectomy.

This policy does not apply to hysterectomy performed for gynecologic malignant conditions. For hysterectomy performed as part of gender transition or gender‑affirming care, refer to Medical Policy 7.01.557 — Gender Transition/Affirmation Surgery and Related Services.

Hysterectomy is considered inappropriate, and therefore may be determined not medically necessary, when it is recommended without adequate diagnostic evaluation or without a documented trial of reasonable alternative therapies for non‑emergent, non‑oncologic indications. Emergency situations such as life‑threatening uterine hemorrhage are exceptions to this expectation.

Coding and place-of-service

Place of Service (Professional Claims Codes)Revenue

19	Off-Campus-Outpatient Hospital
21	Inpatient Hospital
22	On Campus-Outpatient Hospital
24	Ambulatory Surgical Center

Historically referenced codes (removed from policy in 2014)mixed

58200	CPT code listed historically (removed from policy; provided for informational purposes in 2014 history)
58210	CPT code listed historically (removed from policy; provided for informational purposes in 2014 history)
58240	CPT code listed historically (removed from policy; provided for informational purposes in 2014 history)
58285	CPT code listed historically (removed from policy; provided for informational purposes in 2014 history)
58548	CPT code listed historically (removed from policy; provided for informational purposes in 2014 history)
58951-59525	Range of CPT codes listed historically (removed from policy; informational)
68.61	ICD-9 procedure code listed historically (removed)
68.71	ICD-9 procedure code listed historically (removed)

Provider requirements, documentation, and site-of-service rules

Prior Authorization

Place of service and prior authorization (setting-specific)

Place of service affects billing and prior authorization. Claims should use the appropriate professional place-of-service code: 19 Off-Campus-Outpatient Hospital, 21 Inpatient Hospital, 22 On Campus-Outpatient Hospital, or 24 Ambulatory Surgical Center. Prior authorization or site-of-service review requirements may vary by setting; confirm plan-specific requirements before scheduling procedures.

Place-of-service codes: 19, 21, 22, 24
Verify prior authorization requirements for the facility setting

Denial Risk

Denial risk and site-of-service

Site-of-service review is required for laparoscopic assisted vaginal hysterectomy (LAVH) and vaginal hysterectomy. Authorization decisions may be influenced by the site-of-service review outcome. Although denials have historically been rare, insufficient documentation of evaluation or alternatives can increase denial risk, and the determined site of service may affect authorization.

Site-of-service review required for LAVH and vaginal hysterectomy
Denials historically rare but possible when documentation or evaluation is insufficient

Documentation Required

Documentation of evaluation and alternative therapies

Before elective hysterectomy for non-malignant, non-emergent indications, document a complete diagnostic evaluation and that conservative or less invasive alternative therapies were considered and attempted when clinically appropriate. Exceptions apply in life-threatening emergencies (for example, uncontrolled uterine hemorrhage). The medical record should include objective findings, diagnostic test results, and rationale for proceeding to hysterectomy.

Document adequate diagnostic evaluation (history, exam, relevant imaging/lab) prior to elective hysterectomy
Life‑threatening emergencies may justify proceeding without documented alternatives

Documentation Required

Documentation expectations (history notes)

Maintain clear history notes that record the diagnostic workup, discussions of alternatives, and the patient's informed decision. If the patient declines alternative therapies, that refusal must be documented. Policy history clarifications emphasize documenting attempts, contraindications, or technical inability to perform certain diagnostic procedures (for example, endometrial sampling) within required timeframes when applicable.

Document refusal of alternatives if the patient declines
Record attempts or contraindications to diagnostic procedures (e.g., endometrial sampling) and timing (e.g., within prior 12 months when specified)

Note

Attempt alternatives before hysterectomy

Providers should consider and, when appropriate, attempt less invasive alternatives prior to recommending hysterectomy for non-malignant conditions. Examples include medical management, endometrial sampling or D&C where indicated, uterine-sparing procedures (such as uterine artery embolization for fibroids), and other guideline-recommended treatments. The recommendation for hysterectomy should reflect consideration of fertility plans and patient preferences.

Attempt and document conservative therapies prior to elective hysterectomy for non-oncologic indications
Consider uterine-sparing procedures (e.g., fibroid UAE) and medical management where appropriate
Include discussion of childbearing plans in decision-making

Documentation Required

Consideration of alternatives

When recommending hysterectomy for non-malignant indications, explicitly document that alternatives were considered and why they were or were not appropriate. Lack of adequate evaluation or failure to try alternatives has historically been a common reason for findings that hysterectomy was not appropriately recommended.

Document rationale for choosing hysterectomy over less invasive options
Include diagnostic evidence and prior treatment history to support medical necessity

Definitions and procedures

Fibroid Embolization — uterine‑sparing minimally invasive procedure definition

DefinitionA minimally invasive uterine‑sparing procedure in which a substance is delivered through a catheter to occlude uterine artery blood flow to fibroids, causing them to shrink.

PurposeIntended to reduce symptoms from uterine leiomyomata (fibroids) while preserving the uterus and fertility potential when feasible.

TechniquePerformed via transcatheter delivery into uterine arteries (uterine artery embolization / fibroid embolization).

Clinical contextListed in the policy as an alternative, less invasive option to hysterectomy for symptomatic fibroids.

Hysterectomy — definition of surgical removal and approaches

DefinitionSurgical removal of the uterus, sometimes including the cervix; may be performed with salpingo‑oophorectomy (removal of ovaries and fallopian tubes).

Routes/approachesPerformed via abdominal incision or through the vagina; selection of approach depends on diagnosis, uterine size, patient factors, and surgeon judgment.

Reproductive consequenceResults in permanent loss of ability to become pregnant and bear children.

Procedure selectionExtent (subtotal, total, radical) is chosen based on diagnosis and clinical need; radical hysterectomy involves more extensive removal of adjacent structures and lymphatics.

Stages of Uterine Prolapse — Stage 1–4 descriptions

Stage 1Cervix is in the upper half of the vagina.

Stage 2Cervix has descended nearly into the opening of the vagina (introitus).

Stage 3Cervix has protruded out of the vagina.

Stage 4Cervix is completely out of the vagina.

Pelvic floor disorder (PFD) — definition

DefinitionA condition resulting from weakening or injury of the pelvic connective tissue and muscles.

Common manifestationsMost commonly presents as pelvic organ prolapse involving the uterus, bladder, or bowel.

Clinical relevancePFD may contribute to indications for pelvic surgery, including procedures addressing symptomatic prolapse.

Uterine sparing procedure — examples

ExamplesFibroid uterine artery embolization (UAE) and fibroid embolization are listed as uterine‑sparing procedures added to the policy as alternatives to hysterectomy.

RolePresented as less invasive options to consider and document prior to elective hysterectomy for non‑malignant indications when appropriate.

Policy history noteFibroid UAE and fibroid embolization were specifically added to the policy definitions and examples in historical updates.

Policy revision history

2013-02-11policy_creation

New policy created and added to surgery classification; approved with a 90-day provider notification hold and effective May 19, 2013.

2014-02-10annual_review

Annual review and guideline revisions, including modification to MCG criteria and other clarifications.

2022-11-01interim_review

Interim review approved October 11, 2022; effective for dates of service on or after February 3, 2023; clarified applicability for gender transition/affirming hysterectomy and that policy does not apply to gynecologic malignant conditions.

2023-01-01interim_review

Interim review approved December 13, 2022; medical necessity criteria for abnormal bleeding separated for premenopausal and postmenopausal individuals.

2023-08-01annual_review

Annual review approved July 10, 2023; policy reviewed and references added with no change to policy statements.

2024-03-01interim_review

Interim review approved February 26, 2024; clarified endometrial sampling and biopsy requirements for pre- and postmenopausal individuals based on endometrial stripe measurements.

2024-09-01annual_review

Annual review approved August 13, 2024; clarified endometrial sampling criteria to include inability to perform sampling or unsuccessful attempts and added related clarifications under uterine fibroids.

2025-02-01annual_review

Annual review approved January 13, 2025; added dilation and curettage (D&C) as an alternative to endometrial sampling for premenopausal women with menometrorrhagia.

2025-08-01minor_update

Minor updates in August 2025: removed a related policy from Related Policies and moved professional claims codes to Related Information; formatting clarifications regarding D&C timing were made.

2026-03-01annual_reviewLatest

Annual review approved February 9, 2026; references updated and minor edits to policy criteria for clarity with no change to policy intent.

OpenPayer

Hysterectomy for Non-Malignant Conditions

Coverage criteria and medical necessity

Coding and place-of-service

Provider requirements, documentation, and site-of-service rules

Background and scope

Definitions and procedures

Policy revision history