ModifiedUnitedHealthcarePolicy CS314IN.06

Hysterectomy (Indiana-only coverage criteria)

This policy governs medical necessity and coverage guidance for hysterectomy procedures for UnitedHealthcare members in Indiana, referencing state-specific provider guidance and InterQual criteria. It affects providers requesting coverage or prior authorization for hysterectomy-related services in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (Indiana-only coverage criteria)

Policy CodePolicy CS314IN.06

Change TypeCoverage criteria and documentation clarifications

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionRefer to the Indiana Health Coverage Programs Provider Reference Module for specific coverage criteria and ensure medical records fully document medical necessity.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction to 'refer to the Indiana Health Coverage Programs Provider Reference Module: Obstetrical and Gynecological Services for information and coverage for hysterectomies' with 'refer to the Indiana Health Coverage Programs Provider Reference Module: Obstetrical and Gynecological Services for coverage criteria'.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether clinical criteria for coverage are met.

Indiana-onlygeographic applicability

InterQual referencedclinical criteria source

BRCA1/BRCA2BRCA indication noted

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Coverage Criteria and Medical Necessity

General medical necessity criteria (references)

Covered when documented medical necessity per the referenced external criteria is met.

State-specific requirement: Member care must meet Indiana Health Coverage Programs Provider Reference Module: Obstetrical and Gynecological Services for coverage determination

State module governs specific Indiana coverage

Clinical criteria: Clinical coverage criteria use InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy to determine medical necessity

InterQual determinations are authoritative for clinical necessity

BRCA mutation context: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation

Policy explicitly states this indication

Coverage rationale and required references

Coverage determinations should follow BOTH UnitedHealthcare policy and applicable federal/state/contractual requirements; clinicians should consider professional guidance when evaluating indications.

General coverage governance: Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; in the event of conflict, those govern.

Documentation may be required to assess whether clinical criteria are met.

Clinical indications from societies: Hysterectomy can be considered for severe symptoms from endometriosis or adenomyosis after failure of other treatments and when fertility is not desired; consider individualization for BRCA carriers and tamoxifen users per society guidance.

Refer to ACOG, SOGC, NCCN, and NICE guidance as applicable.

Device safety consideration: When laparoscopic morcellation is considered, observe FDA contraindications and boxed warning; avoid morcellation if tissue is known or suspected malignancy or in peri/postmenopausal patients when en bloc removal is feasible.

Inform patients of morcellator risks.

Evidence evaluating routine prophylactic hysterectomy at the time of risk‑reducing salpingo‑oophorectomy (RRSO/RRBSO) for individuals with pathogenic BRCA1/BRCA2 variants is mixed. Systematic reviews and cohort studies report a two‑ to three‑fold increased risk of endometrial cancer in BRCA carriers in some analyses, but authors consistently note limitations and insufficient evidence to support routine hysterectomy for all carriers. Multiple reviews conclude that prophylactic hysterectomy may be considered in individualized cases — particularly when there is a history of or planned tamoxifen use — after careful risk‑benefit discussion with the patient.

Summary guidance in this policy therefore treats hysterectomy in the BRCA context as a potential, individualized option rather than a universally indicated procedure; clinical decisions should reflect the available evidence, patient risk factors (including tamoxifen exposure), and the patient’s values and preferences.

The policy includes the FDA boxed warning and contraindications for laparoscopic power morcellators. The labeling warns that uterine tissue may contain unsuspected cancer and that morcellation during fibroid surgery can spread malignant tissue and negatively affect survival; this risk should be disclosed to patients. Product labeling lists specific contraindications: morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy, and they are contraindicated for removal of uterine tissue containing suspected fibroids in patients who are peri‑ or postmenopausal or when en bloc removal (for example vaginally or via mini‑laparotomy) is feasible.

This policy does not recommend routine prophylactic hysterectomy for all individuals with BRCA1/BRCA2 mutations. Multiple meta‑analyses and cohort studies report conflicting results and limitations; although prophylactic hysterectomy may reduce some uterine cancer risk and may be reasonable in select patients (for example those with tamoxifen exposure), the evidence does not support blanket recommendation for all carriers. Decisions should be individualized and documented in the medical record, including discussion of risks, benefits, and alternatives.

Use of laparoscopic power morcellators in circumstances that are contraindicated by FDA product labeling is considered inappropriate. The FDA contraindicates morcellation when the tissue is known or suspected to contain malignancy and for removal of suspected fibroid tissue in peri‑ or postmenopausal patients when en bloc removal is possible. Providers must follow these device safety warnings and ensure morcellation is not used in these situations.

Procedure Coding

Abdominal and Laparoscopic CPT CodesCPT

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 (corpus and cervix) ... 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.

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Vaginal and Laparoscopic-Assisted Vaginal CPT CodesCPT

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.
58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less.

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Prior authorization management notemixed

*	Codes labeled with an asterisk (*) are not managed for medical necessity review for the state of Indiana at the time this policy became effective; refer to the most up to date prior authorization list for Indiana at Prior Authorization and Notification: UnitedHealthcare Community Plan of Indiana.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization: Verify Indiana-specific Requirements

Prior authorization and notification requirements for Indiana are determined by UnitedHealthcare Community Plan of Indiana. Verify the most up-to-date Indiana-specific prior authorization list at Prior Authorization and Notification: UnitedHealthcare Community Plan of Indiana before submitting a request.

Follow Indiana-specific PA list — prior authorization and notification requirements determined by UnitedHealthcare Community Plan of Indiana

Note

Verify Applicable Benefits and Requirements

Before applying this policy, confirm the member's benefits, federal/state/contractual requirements, and any plan-specific rules that may affect coverage. In the event of conflict, applicable federal, state, or contractual requirements govern coverage decisions.

Check member benefits and plan contract for exclusions or special provisions
Ensure state program (Indiana Health Coverage Programs) requirements are reviewed for applicable coverage

Background and Context

A hysterectomy is a surgical procedure to remove the uterus and may also include removal of fallopian tubes and ovaries. Procedures may be classified as total (removal of uterus and cervix) or supracervical (partial removal), and may be performed via abdominal, vaginal, laparoscopic, laparoscopic‑assisted vaginal, or robotic approaches. Indications commonly addressed by hysterectomy include benign conditions such as fibroids, endometriosis, adenomyosis, pelvic organ prolapse, and abnormal uterine bleeding; in BRCA mutation carriers hysterectomy may be considered in the context of risk‑reducing salpingo‑oophorectomy when clinically appropriate.

Definitions

Total hysterectomy

DefinitionTotal hysterectomy: surgical removal of the entire uterus including the cervix.

Typical componentsMay include removal of ovaries and fallopian tubes depending on indication and surgical plan.

Common indicationsBenign conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding.

Supracervical hysterectomy

DefinitionSupracervical (partial) hysterectomy: removal of the upper part of the uterus while the cervix is left in place.

SynonymAlso called subtotal hysterectomy.

Clinical note

Revision History

2026-02-01policy_revisionLatest

Revised Coverage Rationale to instruct referral to the Indiana Health Coverage Programs Provider Reference Module: Obstetrical and Gynecological Services for 'coverage criteria' (replacing prior wording referencing 'information and coverage for hysterectomies'); added clarifying language to Medical Records Documentation noting that benefit coverage is governed by federal, state, or contractual requirements, that medical records may be required to assess clinical criteria, and specifying required documentation elements (relevant medical history, physical exam, and diagnostic test results) which must be legible and available upon request.