ModifiedUnitedHealthcarePolicy CS196PA.I

Hysterectomy Pa Cs

State-specific UnitedHealthcare medical policy governing coverage of hysterectomy procedures for members in Pennsylvania; references Pennsylvania Code Title 55, Chapter 1141.59 for noncompensable services and uses InterQual criteria for medical necessity determinations. Includes applicable CPT procedure codes, documentation requirements, clinical background and guideline citations.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy Pa Cs

Policy CodePolicy CS196PA.I

Change TypeMODIFIED

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionFor Pennsylvania members, verify coverage criteria against Pennsylvania Code Title 55, Chapter 1141.59 and the plan's PARP; maintain legible medical records with relevant history, exam, and diagnostic results to support medical necessity and make them available upon request.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the Pennsylvania Code, Title 55, Chapter 1141.59: Noncompensable services for coverage criteria.

Added language to Medical Records Documentation Used for Reviews detailing documentation expectations to support medical necessity: records must contain relevant history, physical exam, and diagnostic test/procedure results; must be legible, maintained, and made available upon request; documentation may be required but does not guarantee coverage.

Updated Clinical Evidence and References sections to reflect the most current information (literature reviews and guideline citations).

Pennsylvania-onlyGeographic scope

InterQualMedical necessity source

Coverage Summary

State-specific UnitedHealthcare medical policy (Policy No. CS196PA.I) governing coverage of hysterectomy procedures for members in Pennsylvania only. The policy is effective 04/01/2026 and explicitly directs readers to the Pennsylvania Code, Title 55, Chapter 1141.59 for state-specific noncompensable services and coverage criteria. Medical necessity determinations reference InterQual® CP: Procedures, Hysterectomy +/- BSO or bilateral salpingectomy as the clinical criteria source. The policy lists applicable CPT procedure codes for abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal hysterectomy (representative CPT codes include 58150, 58180, 58541–58544, 58570–58573, 58260–58294, 58550–58554). Indications summarized in the policy include treatment of benign conditions (for example, uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding) and states that hysterectomy is proven and medically necessary for management of individuals with a BRCA1 or BRCA2 gene mutation. Overall coverage stance is mixed: some indications (BRCA carriers and other circumstances meeting InterQual criteria) are identified as medically necessary, whereas other requests must meet state code, contract, and InterQual criteria and may be evaluated case-by-case.

Policy metadata and dates

policy_numberCS196PA.I

subjectHysterectomy (Pennsylvania only)

effective_date2026-04-01

last_review2026-04-01

statusMODIFIED

Medical Necessity Criteria

State-Specific Application

This medical policy only applies to the state of Pennsylvania. Any requests not meeting criteria set in the PARP will be evaluated case-by-case.

ALL of the following

Coverage criteria for hysterectomy are governed by Pennsylvania Code, Title 55, Chapter 1141.59: Noncompensable Services

General Non State-Specific Coverage Criteria

Hysterectomy is considered proven and medically necessary in certain circumstances; specific medical necessity criteria are determined by InterQual CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy.

ANY of the following

Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation
InterQual criteria must be consulted for detailed medical necessity determinations

Procedure Coding

Applicable CPT - Abdominal hysterectomyCPT

58150	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
58152	Total abdominal hysterectomy; with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)
58180	Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

Applicable CPT - Laparoscopic hysterectomyCPT

58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
58542	Laparoscopy, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543	Laparoscopy, supracervical hysterectomy, for uterus greater than 250 g
58544	Laparoscopy, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571	Laparoscopy, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572	Laparoscopy, with total hysterectomy, for uterus greater than 250 g
58573	Laparoscopy, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Applicable CPT - Vaginal hysterectomyCPT

58260	Vaginal hysterectomy, for uterus 250 g or less
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
58263	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy
58270	Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
58290	Vaginal hysterectomy, for uterus greater than 250 g
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58292	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
58294	Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Applicable CPT - Laparoscopic-assisted vaginal hysterectomyCPT

58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
58552	Laparoscopy, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553	Laparoscopy, with vaginal hysterectomy, for uterus greater than 250 g
58554	Laparoscopy, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Provider Actions & Requirements

Documentation Required

Medical record documentation requirement

Providers must maintain legible medical records that fully support the medical necessity for the requested hysterectomy. Documentation should include relevant medical history, the physical examination, and results of pertinent diagnostic tests or procedures. Records must be maintained in the patient's chart and made available upon request. Medical records may be required to assess whether clinical criteria for coverage are met, but submission of documentation does not guarantee coverage.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Legible documentation maintained in the patient's medical record
Make records available upon request

Background & Evidence

A hysterectomy is a surgical procedure to remove the uterus and, in some cases, the ovaries and fallopian tubes. Approaches described include vaginal, abdominal, laparoscopic, laparoscopic-assisted vaginal, and robotic-assisted techniques. Common indications cited are benign conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding. The policy also discusses prophylactic hysterectomy in the context of BRCA1/2 mutation carriers: multiple systematic reviews and cohort studies are summarized showing a mixed evidence base (some reports of a two- to three-fold increased endometrial cancer risk in BRCA carriers) and the policy notes that routine prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy remains controversial and should be individualized, considering factors such as tamoxifen exposure and other uterine cancer risk factors. For chronic pelvic pain/adenomyosis, randomized trials cited suggest medical alternatives (for example, the levonorgestrel-releasing intrauterine system) can be effective and that hysterectomy is an option when other treatments fail and fertility is no longer desired.

Evidence summaries

Definitions

Revision History

04/01/2026policy_revisionLatest

Added instruction to refer to the Pennsylvania Code, Title 55, Chapter 1141.59 for coverage criteria (Noncompensable Services).

04/01/2026policy_revisionLatest

Added language to Medical Records Documentation Used for Reviews detailing documentation expectations: benefit coverage is determined by federal, state, or contractual requirements and applicable laws; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; patient medical record must contain documentation that fully supports medical necessity (including relevant medical history, physical exam, and results of pertinent diagnostic tests/procedures); documentation must be legible, maintained in the medical record, and made available upon request.