CurrentUnitedHealthcarePolicy CS196PA.I

Hysterectomy (for Pennsylvania Only) – Community Plan Medical Policy

State-specific UnitedHealthcare medical policy for hysterectomy that applies only to Pennsylvania members; references Pennsylvania Code for coverage criteria and uses InterQual CP criteria for medical necessity for hysterectomy and related procedures. Includes applicable CPT procedure code list, documentation requirements, and clinical background (BRCA mutations, chronic pelvic pain, guidelines).

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Pennsylvania Only) – Community Plan Medical Policy

Policy CodePolicy CS196PA.I

Change TypeState-specific criteria and documentation clarifications (added/revised)

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure the medical record contains relevant medical history, physical exam, and diagnostic test results that fully support medical necessity; records must be legible and available upon request.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale State-Specific Criteria: Added instruction to refer to the Pennsylvania Code, Title 55, Chapter 1141.59: Noncompensable services for coverage criteria.

Medical Records Documentation Used for Reviews: Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and documenting requirements for medical necessity evidence.

Supporting Information: Updated Clinical Evidence and References sections to reflect the most current information.

1State-specific policy (PA)

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Coverage Summary

This is the Pennsylvania‑specific UnitedHealthcare medical policy for Hysterectomy (Policy #: CS196PA.I), effective April 1, 2026 with last review on April 1, 2026. The policy applies only to the state of Pennsylvania, references Pennsylvania Code Title 55, Chapter 1141.59 for coverage criteria, and uses InterQual CP criteria for medical necessity decisions. The policy’s overall coverage stance is mixed.

Key Policy Details

Policy NumberCS196PA.I

PayerUnitedHealthcare

StatePennsylvania

Effective Date2026-04-01

Last Review2026-04-01

Coverage Stancemixed

Medical-Necessity Criteria

Applicability / State-specific rule

Policy applies only to Pennsylvania and defers to state regulations for coverage criteria:

State applicability: This Medical Policy only applies to the state of Pennsylvania.
PARP case-by-case: Any requests for services that do not meet criteria set in the PARP will be evaluated on a case-by-case basis.
Refer to PA Code: For coverage criteria, refer to the Pennsylvania Code, Title 55, Chapter 1141.59: Noncompensable Services.

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Provider Actions

Prior Authorization

Refer to state and InterQual criteria for coverage determination

Prior authorization and coverage decisions for hysterectomy in Pennsylvania should follow state regulations and InterQual clinical criteria; requests that do not meet PARP criteria may be reviewed on a case-by-case basis.

Refer to Pennsylvania Code, Title 55, Chapter 1141.59: Noncompensable Services.
InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy.
Requests not meeting PARP criteria will be evaluated on a case-by-case basis.

Documentation Required

Support medical necessity with chart documentation

Support medical necessity with complete, legible chart documentation that is available upon request to demonstrate the clinical need for the requested hysterectomy.

Applicable CPT Codes

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, 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 - 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 - 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)

Background and Evidence

Hysterectomy types described include total and supracervical (partial) hysterectomy and can be performed vaginally, abdominally, or laparoscopically/robotically. Common benign indications noted are uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding.

For individuals with BRCA1/2 mutations, multiple systematic reviews and cohort studies report a two- to three-fold increased risk of endometrial cancer in some analyses, but evidence is mixed and routine prophylactic hysterectomy at the time of RRSO/RRBSO is not uniformly recommended. Some analyses indicate hysterectomy at the time of risk‑reducing salpingo‑oophorectomy may be an option, particularly when tamoxifen exposure or other risk factors exist, and guideline organizations recommend individualized discussion of risks and benefits.

The policy references guideline positions: ACOG notes tamoxifen increases uterine cancer risk and recommends counseling/monitoring and consideration of hysterectomy for atypical hyperplasia; NCCN recommends discussing concurrent hysterectomy at RRSO for BRCA carriers; SOGC advises individualized decision‑making on concurrent hysterectomy with RRSO.

Evidence type	Notes
Systematic reviews/meta-analyses	Multiple systematic reviews and meta-analyses (Gasparri 2022; Nahshon 2021; Matanes 2020) report mixed evidence regarding prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO) for BRCA1/2 carriers. Reviews note a 2–3-fold increased uterine cancer risk in some BRCA carriers and that tamoxifen use is associated with a two- to three-fold increase in uterine malignancies; authors conclude routine hysterectomy at RRSO is not strongly supported but may be considered for tamoxifen-exposed individuals after individualized risk–benefit discussion.
Randomized trials	Randomized controlled trials for adenomyosis and menorrhagia compare levonorgestrel-releasing IUS (LNG-IUS) versus hysterectomy and show mixed results: LNG-IUS and medical options provide improvements in bleeding and pelvic pain, with some studies reporting superior psychological and social quality-of-life effects for LNG-IUS; both approaches reduced pain over time with variable differences across time points, indicating hysterectomy is one option after failure of other treatments.

Evidence type

Notes

Systematic reviews/meta-analyses

Multiple systematic reviews and meta-analyses (Gasparri 2022; Nahshon 2021; Matanes 2020) report mixed evidence regarding prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO) for BRCA1/2 carriers. Reviews note a 2–3-fold increased uterine cancer risk in some BRCA carriers and that tamoxifen use is associated with a two- to three-fold increase in uterine malignancies; authors conclude routine hysterectomy at RRSO is not strongly supported but may be considered for tamoxifen-exposed individuals after individualized risk–benefit discussion.

Randomized trials

Randomized controlled trials for adenomyosis and menorrhagia compare levonorgestrel-releasing IUS (LNG-IUS) versus hysterectomy and show mixed results: LNG-IUS and medical options provide improvements in bleeding and pelvic pain, with some studies reporting superior psychological and social quality-of-life effects for LNG-IUS; both approaches reduced pain over time with variable differences across time points, indicating hysterectomy is one option after failure of other treatments.

RRSO — Risk‑reducing salpingo‑oophorectomy: prophylactic removal of the fallopian tubes and ovaries to reduce ovarian cancer risk, often discussed in BRCA1/2 carriers.

RRBSO — Risk‑reducing bilateral salpingo‑oophorectomy: bilateral removal of ovaries and fallopian tubes for risk reduction (term used interchangeably with RRSO in literature and guidelines).

PARP — In this policy context, refers to the Pennsylvania Access and Reimbursement Parameters (procedural/state review reference) used for state‑specific coverage and prior authorization guidance.

Revision History

04/01/2026addedLatest

Coverage Rationale State-Specific Criteria: Added instruction to refer to the Pennsylvania Code, Title 55, Chapter 1141.59: Noncompensable services for coverage criteria. (Material change)

04/01/2026addedLatest

Medical Records Documentation Used for Reviews: Added documentation requirements specifying that benefit coverage is determined by federal, state, or contractual requirements; medical records may be required to assess clinical criteria; patient's record must fully support medical necessity and include relevant medical history, physical exam, and diagnostic test results; documentation must be legible and made available upon request. (Material change)