ModifiedUnitedHealthcarePolicy CS196KS.02

Hysterectomy (for Kansas Only)

State-specific UnitedHealthcare Community Plan medical policy governing indications, coding, and documentation for hysterectomy for members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Kansas Only)

Policy CodePolicy CS196KS.02

Change TypeMaterial revisions and clarifications (state cross-reference, documentation, removal of prior indication language)

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionEnsure medical records document relevant history, physical exam, and diagnostic test results to support medical necessity and make them available upon request.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the Kansas Medical Assistance Program Professional Fee-For-Service Provider Manual for medical necessity clinical coverage criteria for hysterectomy.

Removed language indicating hysterectomy is proven and medically necessary for management of chronic pelvic pain.

Added explicit medical records documentation language describing documentation that may be required to assess medical necessity.

Updated clinical evidence and references sections to reflect the most current information.

State-specificapplies to

BRCA1/2BRCA indication

InterQualexternal criteria

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Coverage Criteria and Clinical Guidance

Medical necessity coverage (state-specific + InterQual)

Covered when supported by state-specific criteria and InterQual clinical criteria

State application: Policy applies only to Kansas; follow Kansas Medical Assistance Program clinical coverage criteria for hysterectomy

Refer to Kansas Medical Assistance Program Ambulance Fee-For-Service Provider Manual for state-specific medical necessity criteria

External clinical criteria: When state-specific criteria do not provide complete guidance, coverage is determined using InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy clinical criteria

UnitedHealthcare uses InterQual criteria for primary medical/surgical determinations; when InterQual lacks applicable criteria, UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment may be used

Indications referenced: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation, and may be medically necessary in certain circumstances per InterQual clinical criteria

BRCA1/2 specified as proven indication in the policy; see InterQual for other covered indications

Clinical guidance items (not algorithmic criteria)

Professional guidance and individualized decision-making recommendations

BRCA-related RRSO and hysterectomy discussion: NCCN: Individuals with a pathogenic/likely pathogenic BRCA1/2 variant should discuss risks and benefits of concurrent hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO); recommended timing for RRSO is typically 35–40 years for BRCA1 and 40–45 years for BRCA2 unless family history warrants earlier intervention.

Guidance for shared decision-making; not an automatic coverage rule

Tamoxifen and atypical endometrial hyperplasia: ACOG: Women receiving tamoxifen should be counseled about increased risks of endometrial proliferation and malignancy; if atypical endometrial hyperplasia develops and tamoxifen continuation is recommended, hysterectomy should be considered after individualized assessment.

Clinical management recommendation rather than an algorithmic coverage criterion

Chronic pelvic pain, endometriosis, adenomyosis: SOGC and NICE: Hysterectomy may be an acceptable option for endometriosis or adenomyosis (with ovarian conservation) when severe symptoms persist despite other treatments and when fertility is not desired; NICE defines chronic pelvic pain as pain lasting >= 6 months.

This section of the policy does not list explicit procedural exclusions within the coverage criteria text. Coverage determinations rely on the interplay of state-specific clinical coverage criteria and external clinical decision tools: for members in Kansas, refer to the Kansas Medical Assistance Program manual for applicable medical necessity clinical coverage criteria, and for clinical details UnitedHealthcare references the InterQual® CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy criteria.

Laparoscopic power morcellators carry device-specific safety warnings and contraindications. The policy follows FDA guidance and the device labeling: power morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy. They are also contraindicated for removal of uterine tissue containing suspected fibroids in peri- or post-menopausal patients or when en bloc removal (for example via the vagina or mini-laparotomy) is feasible, because morcellation may spread occult uterine malignancy and adversely affect long-term outcomes. These risks should be considered and discussed with the patient when morcellation is contemplated.

The addition of a prophylactic hysterectomy at the time of risk‑reducing salpingo‑oophorectomy (RRSO) for patients with BRCA1/2 pathogenic or likely pathogenic variants is controversial. Systematic reviews and cohort studies report a two- to three‑fold increased risk of endometrial cancer in some BRCA carriers, and prophylactic hysterectomy may prevent some endometrial cancers and could be considered in specific circumstances (for example, concurrent or anticipated tamoxifen use or need for hormone therapy). However, the evidence does not uniformly support routine prophylactic hysterectomy for all BRCA1/2 carriers; a careful individualized risk–benefit discussion is recommended.

Policy language was revised to remove the prior assertion that hysterectomy is proven and medically necessary for the management of chronic pelvic pain. The current policy no longer states hysterectomy is universally indicated for chronic pelvic pain; instead, management decisions should reflect updated evidence, professional guidance, and individualized assessment.

Procedure Codes and Coding Notes

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 or without removal of tube(s), with or without removal of ovary(s); 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-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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inv-09: Uterus weight threshold — numeric value for surgical planning/coding

Uterus weight threshold250 g

Codes referencing threshold (laparoscopic supracervical)58541, 58542 (for uterus 250 g or less); 58543, 58544 (for uterus greater than 250 g)

Codes referencing threshold (laparoscopic total)58570, 58571 (for uterus 250 g or less); 58572, 58573 (for uterus greater than 250 g)

Codes referencing threshold (vaginal/laparoscopic-vaginal)58260–58270 series and 58550, 58552 (for uterus 250 g or less); 58290–58294 and 58553, 58554 (for uterus greater than 250 g)

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Some services referenced by this policy may require prior authorization. Providers should verify prior authorization requirements and obtain approval when required by the member's benefit plan, state law, or contractual terms before providing services.

Affected codes: see Applicable Codes section for procedure and diagnosis codes — listing is reference only and does not guarantee coverage or authorization.
Prior authorization rules may vary by state/contract; always check the member’s plan and applicable state regulations.

Documentation Required

Required Medical Record Documentation

Documentation supporting medical necessity must be included in the patient’s medical record and made available upon request. This documentation should be legible and maintained in the medical record.

Required elements include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.

Background and Clinical Context

A hysterectomy is a surgical procedure to remove the uterus and, when performed, may include removal of the ovaries and fallopian tubes. It is used to treat benign gynecologic conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding. Surgical approaches include vaginal, abdominal, laparoscopic, or robotic techniques, and the procedure may be performed as a total hysterectomy (removal of the uterus including cervix) or a supracervical (subtotal) hysterectomy (retaining the cervix).

Definitions and Terminology

inv-19: Total hysterectomy — definition

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

Typical procedures includedMay be performed abdominally, vaginally, laparoscopically, or with robotic assistance; may include removal of fallopian tubes and/or ovaries depending on indication.

Relevant CPT examples58150, 58152 (abdominal total hysterectomy); 58570–58573 (laparoscopic total hysterectomy).

inv-20: Supracervical hysterectomy — definition

DefinitionSupracervical (subtotal) hysterectomy: removal of the upper part of the uterus with the cervix retained.

Typical approachesCan be performed abdominally or laparoscopically; may include removal of tubes and/or ovaries as indicated.

Policy Revision History

2026-03-01policy_revision

Added state-specific cross-reference instructing referral to the Kansas Medical Assistance Program Provider Manual for medical necessity clinical coverage criteria for hysterectomy.

2026-03-01policy_revision

Removed prior language stating hysterectomy is proven and medically necessary for management of chronic pelvic pain.

2026-03-01policy_revisionLatest