CurrentUnitedHealthcarePolicy CS196NM.C

Hysterectomy (for New Mexico Only)

UnitedHealthcare medical policy specific to New Mexico governing indications, documentation, applicable coding, and references for hysterectomy procedures; refers to state-specific NMAC rules and InterQual criteria for clinical coverage determinations.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for New Mexico Only)

Policy CodePolicy CS196NM.C

Change TypeState-specific update; documentation requirements

Effective DateApr 1, 2026

Next Review Date

Key ActionMaintain legible medical record documentation that fully supports medical necessity including relevant medical history, physical exam, and diagnostic test results; make available upon request.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the New Mexico Administrative Code (NMAC), Title 8, Chapter 310, Part 2: General Benefit Description for coverage criteria.

Added language clarifying medical records documentation requirements to assess medical necessity.

Updated Clinical Evidence and References sections to reflect current information.

1State-specific policy (New Mexico)

BRCA1/BRCA2Explicit covered indication mentioned

InterQualUses InterQual criteria for medical necessity

Coverage Summary

Scope: UnitedHealthcare medical policy for hysterectomy that applies only to the state of New Mexico, governing indications, required documentation, applicable CPT coding, and references used for coverage determinations. Coverage stance: mixed — the policy identifies proven/medically necessary uses (including BRCA1/BRCA2 carriers) while deferring many clinical determinations to InterQual criteria and state rules. Subject: surgical removal of the uterus with various approaches (abdominal, vaginal, laparoscopic, robotic) and related procedures (with or without salpingo-oophorectomy). State-specific applicability: this policy applies only to New Mexico and directs reviewers to NMAC Title 8, Chapter 310, Part 2: General Benefit Description for coverage criteria. References and guidance: medical necessity and prior-authorization decisions are guided by the InterQual® CP: Procedures, Hysterectomy +/- BSO/Bilateral Salpingectomy and state rules. Headline clinical note: carriers of BRCA1/BRCA2 pathogenic variants are explicitly called out as an indication where hysterectomy is proven and medically necessary (with additional evidence discussion about prophylactic hysterectomy timing).

Policy metadata

policy_numberCS196NM.C

dates.effectiveApril 1, 2026

dates.last_reviewApril 1, 2026

statusCURRENT

scope_summaryUnitedHealthcare medical policy specific to New Mexico governing indications, documentation, applicable coding, and references for hysterectomy procedures; refers to state-specific NMAC rules and InterQual criteria for clinical coverage determinations.

Medical-Necessity Criteria

State-Specific and Non State-Specific Coverage Criteria

Coverage determinations are governed by state rules and InterQual criteria; hysterectomy is proven and medically necessary in specific circumstances including BRCA1/BRCA2 mutation carriers.

ALL of the following

State notices
- This Medical Policy only applies to the state of New Mexico.
- For coverage criteria, refer to the New Mexico Administrative Code (NMAC), Title 8, Chapter 310, Part 2: General Benefit Description.
- For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy.
Medically necessary indications (examples provided)

Not Covered / Experimental

Coverage stance: mixed. Clinical-evidence nuance: systematic reviews and meta-analyses report mixed conclusions about performing routine prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO) for BRCA1/2 carriers — some studies report increased endometrial cancer risk and potential benefit in select situations (for example, tamoxifen exposure), but overall routine addition of hysterectomy remains controversial. Policy governance: specific indications and determinations of medical necessity are governed by InterQual criteria and New Mexico state rules (NMAC Title 8, Chapter 310, Part 2), which should be consulted for preauthorization and coverage decisions.

Applicable Procedure Codes (CPT)

Applicable Procedure Codes (CPT)CPT

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).
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.

1–10 of 24

1/3

Uterus weight threshold used for coding: 250 g. This threshold is used in CPT descriptors to distinguish codes for uterus ≤250 g versus >250 g and guides selection of the appropriate hysterectomy CPT code based on uterus size and surgical approach.

Provider Actions

Prior Authorization

Refer to state and InterQual criteria for prior authorization decisions

Determine coverage by referencing New Mexico Administrative Code (NMAC) Title 8, Chapter 310, Part 2 and the InterQual® CP: Procedures, Hysterectomy +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy. These references guide prior authorization and medical necessity/coverage determinations for hysterectomy procedures in New Mexico.

Documentation Required

Medical record documentation

Maintain legible medical record documentation that fully supports the medical necessity for the requested hysterectomy. Documentation may be requested for review and should be available upon request to assess whether the member meets clinical criteria for coverage.

Relevant medical history
Physical examination

Background & Evidence Summary

Background: A hysterectomy is the surgical removal of the uterus (total or supracervical) and may include removal of ovaries and fallopian tubes. Surgical approaches include abdominal, vaginal, laparoscopic, and robotic-assisted. Common benign indications include uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding. The policy notes hysterectomy is proven and medically necessary for individuals with BRCA1/BRCA2 mutations and in certain circumstances as defined by InterQual. For chronic pelvic pain and adenomyosis, non-surgical alternatives such as the levonorgestrel-releasing intrauterine system (LNG-IUS) have evidence of improving quality of life and controlling bleeding/pain and may be considered prior to hysterectomy when appropriate.

Evidence

Definitions

RRSORisk‑reducing salpingo‑oophorectomy.

RRBSORisk‑reducing bilateral salpingo‑oophorectomy.

InterQual® CPThird‑party clinical criteria used by UnitedHealthcare to assess medical necessity for procedures.

Revision History

04/01/2026added (material)Latest

Added instruction to refer to the New Mexico Administrative Code (NMAC), Title 8, Chapter 310, Part 2: General Benefit Description for coverage criteria.

04/01/2026added (material)Latest

Added documentation requirements: medical records must contain relevant medical history, physical exam, and pertinent diagnostic test results; documentation must be legible, maintained in the record, and made available upon request to assess medical necessity.

04/01/2026