ModifiedUnitedHealthcarePolicy CS313KY.11

Hysterectomy (for Kentucky Only)

This policy governs medical necessity and coverage considerations for hysterectomy procedures for UnitedHealthcare members in Kentucky, including references to state-specific regulations and InterQual criteria. It affects providers requesting authorization and claims for hysterectomy-related services in Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Kentucky Only)

Policy CodePolicy CS313KY.11

Change TypeState-specific references and documentation requirements added

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProvide complete medical record documentation (history, exam, and pertinent test results) to support medical necessity when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

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

Added language specifying medical records documentation requirements to support medical necessity determinations.

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

InterQualClinical coverage criteria source

KAR 907:003:005State regulation

BRCA1/BRCA2 notedBRCA consideration

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Coverage Criteria

InterQual criteria

Covered when clinical criteria per InterQual are met.

InterQual-based necessity: Hysterectomy is considered proven and medically necessary in certain circumstances when the InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy criteria are met.refer to InterQual

InterQual criteria are external to this document and must be applied for clinical determinations.

BRCA1/BRCA2 and prophylactic hysterectomy considerations

Special considerations and evidence summary regarding BRCA1/BRCA2 mutation carriers and prophylactic hysterectomy.

BRCA mutation consideration: Hysterectomy may be considered for individuals with pathogenic BRCA1 or BRCA2 variants; the literature reports an increased risk (approximately two- to three-fold in some studies) of endometrial cancer in BRCA1/2 carriers but does not support routine prophylactic hysterectomy for all carriers.clinical judgment and individualized patient discussion

Evidence includes systematic reviews, meta-analyses, and cohort studies; tamoxifen exposure and other risk factors may influence the decision to perform concurrent hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO).

Medical therapy alternatives

Alternatives to hysterectomy for chronic pelvic pain and adenomyosis.

Non-surgical alternatives: Levonorgestrel-releasing intrauterine system (LNG-IUS) and medical therapies such as dienogest have randomized and controlled trial evidence demonstrating benefit for control of bleeding and pelvic pain and may be reasonable alternatives to hysterectomy in selected patients.individual trial of appropriate medical therapy as clinically indicated (e.g., documented attempt and response/intolerance)

RCTs show LNG-IUS may provide comparable quality-of-life outcomes in some settings; patient selection and shared decision-making are recommended.

Application of criteria sources

Use of external criteria and state regulations in coverage determinations.

Primary criteria application: Use InterQual® medical/surgical criteria as the primary source for medical necessity determinations for hysterectomy. Refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005 for state-specific service limitations where applicable.

If InterQual® lacks applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines that have been approved by the Kentucky Department for Medicaid Services; NCCN and SOGC guidance may inform individualized decisions such as concurrent hysterectomy with RRSO.

Coverage determinations for hysterectomy in Kentucky are subject to state-specific limits. Refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005: Coverage of physicians services, Section 4, Service Limitations when applying or interpreting the policy for members residing in Kentucky. This policy operationalizes that requirement and directs reviewers to the KAR provision for any specific exclusions or limits that affect coverage decisions.

Use of laparoscopic power morcellators is contraindicated when the tissue to be morcellated is known or suspected to contain malignancy. Product labeling also contraindicates their use for removal of uterine tissue containing suspected fibroids in patients who are peri- or post-menopausal and recommends that the device warning regarding potential spread of unsuspected cancer be shared with patients prior to surgery.

This policy document provides clinical coverage guidance for hysterectomy procedures and references InterQual® criteria and applicable state regulations for decision-making. Where InterQual® or state regulations require documentation or specific process steps, those external criteria and the UnitedHealthcare authorization processes should be followed to determine coverage.

The policy does not endorse routine prophylactic hysterectomy for individuals with pathogenic or likely pathogenic BRCA1/BRCA2 variants. Major guideline sources recommend individualized decision-making: discuss risks and benefits of concurrent hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO) and consider patient-specific factors (including age, family history, and use of agents such as tamoxifen) when planning prophylactic surgery rather than routinely performing hysterectomy.

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 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-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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Uterus weight threshold (coding)

Uterus weight threshold250 g — used to distinguish CPT descriptors for multiple abdominal, laparoscopic, and vaginal hysterectomy codes (e.g., 58541/58570 vs 58543/58572; 58260 vs 58290).

Codes referencing thresholdExamples: 58541/58570 and 58260 describe procedures for uterus 250 g or less; 58543/58572 and 58290 describe procedures for uterus greater than 250 g.

ApplicabilityThreshold applies in CPT code descriptors across abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal hysterectomy code sets listed in this policy.

Chronic pelvic pain duration

Chronic pelvic pain duration>= 6 months — chronic pelvic pain defined as pelvic pain lasting for 6 months or longer per guideline references.

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for the hysterectomy-related CPT codes listed in this policy. Requests for coverage must include a prior authorization submitted to UnitedHealthcare before the procedure is performed unless otherwise specified by the member's benefit plan or applicable state/contractual requirements.

Affected CPT codes: 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58550, 58552, 58553, 58554

Prior Authorization

Prior Authorization and Criteria Source

Prior authorization determinations and clinical review are conducted in accordance with applicable federal, state, and contractual requirements and use InterQual® medical/surgical criteria as the primary source. If InterQual® criteria are not applicable, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines as allowed by Kentucky requirements.

Refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 003, Regulation 005 where state-specific coverage rules apply
Primary clinical criteria source: InterQual® medical/surgical criteria

Background

A hysterectomy is a surgical procedure to remove the uterus and may include removal of the ovaries and fallopian tubes; approaches include vaginal, abdominal, laparoscopic (including robotic), total and supracervical techniques. Indications for hysterectomy for benign disease include symptomatic uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding; chronic pelvic pain (defined as pelvic pain lasting >= 6 months) associated with these conditions may also be an indication when supported by clinical assessment and prior appropriate management.

Definitions

Total hysterectomy

DefinitionRemoval of the entire uterus, including the cervix.

ContextsMay be performed for benign conditions such as fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding.

ApproachesCan be performed vaginally, abdominally, laparoscopically, or with robotic assistance (total hysterectomy variants described in procedure coding).

Supracervical (partial) hysterectomy

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

Coding examplesCPT descriptors include supracervical abdominal hysterectomy (58180) and laparoscopic supracervical hysterectomy codes (58541/58542 for uterus 250 g or less; 58543/58544 for >250 g).