CurrentUnitedHealthcarePolicy CS313KY.11

Hysterectomy Ky Cs

State-specific UnitedHealthcare medical policy for hysterectomy applicable only to Kentucky members, referencing Kentucky Administrative Regulations and InterQual procedural criteria; includes indications (e.g., BRCA1/2 mutation), required documentation, applicable CPT codes, clinical evidence summary, and FDA device information.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy Ky Cs

Policy CodePolicy CS313KY.11

Change TypeState-specific additions; documentation requirements

Effective DateApr 1, 2026

Next Review Date

Key ActionMaintain legible medical records that fully support medical necessity, including relevant history, exam, and diagnostic results, and make them available upon request.

SourceLink

POLICY UPDATE CHANGES

State-Specific Criteria: Added instruction to refer to the Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005 for coverage criteria.

Medical Records Documentation Used for Reviews: Added detailed documentation requirements and statements that documentation may be required to assess clinical criteria and does not guarantee coverage.

Updated supporting information: Clinical Evidence and References sections to reflect current information.

1State-specific policy

MultipleApplicable CPT codes listed

BRCA1/2Explicit covered indication (conditional)

Coverage Summary

This is a state-specific UnitedHealthcare medical policy for hysterectomy that applies only to members in Kentucky. The policy directs users to the Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005 for state coverage criteria and service limitations. UnitedHealthcare uses InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy as the primary clinical criteria for medical necessity determinations. The policy explicitly lists management of individuals with a BRCA1 or BRCA2 gene mutation as an indication in which hysterectomy is considered proven and medically necessary per InterQual, but the overall coverage stance is noted as mixed given the clinical evidence and guideline positions summarized in the supporting information.

Policy metadata

policy_numberCS313KY.11

dates.effectiveApril 1, 2026

dates.last_reviewApril 1, 2026

State-specificYes — applies only to Kentucky

Applicable guidanceInterQual CP; KAR Title 907 Chapter 003 Regulation 005

Brief highlightExplicit covered indication (conditional): BRCA1/2

Medical Necessity Criteria

Application

ALL of the following

Policy applies only to members in Kentucky.

State-Specific Coverage Criteria

ALL of the following

Refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005: Coverage of physicians services, Section 4, Service Limitations for coverage criteria.

Non State-Specific Medical Necessity Criteria

ALL of the following

InterQual use: Medical necessity determinations for hysterectomy follow InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy.
General proven/necessary statement: Hysterectomy is considered proven and medically necessary in certain circumstances per InterQual criteria.
BRCA indication: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation.

Medical Records Documentation Requirements

ALL of the following

Documentation elements: Patient medical record must contain relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures that support medical necessity.
Legibility and availability: Documentation must be legible, maintained in the patient's medical record, and made available upon request.
Records may be requested: Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the services requested.
Benefit determination: Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service.

Applicable Codes

Applicable CPT Codes - 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 Codes - Laparoscopic HysterectomyCPT

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

Applicable CPT Codes - 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 (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control.
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 Codes - Laparoscopic-Assisted Vaginal HysterectomyCPT

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

Maintain legible medical records that fully support medical necessity and make them available upon request. Records should include the patient's relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation may be requested to assess clinical criteria but 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
Records made available upon request

Prior Authorization

Use InterQual criteria for medical necessity determinations

Use the InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy as the primary criteria for medical necessity determinations for hysterectomy. If InterQual does not have applicable criteria, UnitedHealthcare policies/guidelines approved by Kentucky Medicaid may be used as a fallback.

Primary: InterQual® CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy
Fallback: UnitedHealthcare policies/guidelines approved by the Kentucky Department for Medicaid Services when InterQual criteria are not applicable

Documentation Required

Refer to state regulations for coverage limitations

Refer to the Kentucky Administrative Regulations (KAR) — Title 907, Chapter 003, Regulation 005, Section 4 — for state-specific coverage criteria and service limitations. Federal, state, or contractual requirements govern in the event of a conflict with this policy.

Reference: KAR Title 907, Chapter 003, Regulation 005: Coverage of physicians services, Section 4, Service Limitations
In a conflict, federal, state, or contractual requirements for benefit plan coverage prevail

Background & Evidence

A hysterectomy is the surgical removal of the uterus and may include removal of the ovaries and fallopian tubes. Types described include total, supracervical (subtotal), vaginal, abdominal, laparoscopic, and robotic-assisted approaches. Applicable CPT procedure code groupings for abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal hysterectomy are listed in the policy for reference.

Common benign indications for hysterectomy include treatment of uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding. The policy references InterQual criteria as the primary source for assessing medical necessity and notes that hysterectomy is considered proven and medically necessary in certain circumstances per InterQual.

The policy highlights BRCA1/2 gene mutation as an indication discussed in the evidence base: systematic reviews and meta-analyses show mixed findings about the benefit of adding prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO/RRBSO). Guideline positions (NCCN, SOGC, ACOG, NICE) and systematic reviews report that the decision to perform concurrent hysterectomy for BRCA carriers is controversial and should be individualized, with NCCN recommending discussion of concurrent hysterectomy at the time of RRSO.

Evidence summary

Systematic reviews/meta-analyses citedGasparri 2022; Nahshon 2021; Matanes 2020 (multiple systematic reviews/meta-analyses showing mixed evidence on prophylactic hysterectomy in BRCA1/2 carriers; tamoxifen increases uterine malignancy risk)

Guideline referencesACOG, NCCN, NICE, SOGC summarized (NCCN recommends discussion of concurrent hysterectomy at RRSO for BRCA carriers; ACOG and SOGC positions noted)

Hysterectomy: Surgical removal of the uterus; may include removal of ovaries and fallopian tubes. Types include total, supracervical (subtotal), vaginal, abdominal, laparoscopic, and robotic-assisted approaches.

RRSO / RRBSO: Risk-reducing salpingo-oophorectomy (also termed risk-reducing bilateral salpingo-oophorectomy) — removal of the fallopian tubes and ovaries performed to reduce ovarian cancer risk, often considered with discussion of concurrent hysterectomy in select high-risk patients (for example, some individuals with BRCA1/2 mutations).

Revision History

2026-04-01addedLatest

State-Specific Criteria: Added instruction to refer to the Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005 for coverage criteria (Section 4, Service Limitations).

2026-04-01added

Medical Records Documentation Used for Reviews: Added detailed documentation requirements stating benefit coverage is determined by federal, state, or contractual requirements; documentation may be required to assess clinical criteria but does not guarantee coverage; patient medical record must include relevant history, physical exam, and diagnostic test results; documentation must be legible and made available upon request.

2026-04-01revised

Updated supporting information: Clinical Evidence and References sections to reflect current information; archived previous policy version CS313KY.10.