RetiredUnitedHealthcarePolicy CS196LA.C

Hysterectomy (for Louisiana Only) Retired April 1, 2026

Policy governs medical necessity and coding guidance for hysterectomy procedures for UnitedHealthcare members in Louisiana, including covered indications, InterQual criteria reference, procedure codes, and guidance on BRCA-related risk reduction and morcellator contraindications.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Louisiana Only) Retired April 1, 2026

Policy CodePolicy CS196LA.C

Change TypeRetiredcontent revised

Effective DateJune 1, 2025

Next Review DateN/A

Key ActionRefer to InterQual CP: Procedures, Hysterectomy +/- BSO for specific medical necessity authorization criteria.

SourceLink

POLICY UPDATE CHANGES

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

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

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

LouisianaGeographic scope

BRCA1/BRCA2Covered indication noted

Comprehensive listProcedure coding

Apr 1, 2026

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Coverage Criteria

Medical necessity basis

Covered when specific clinical criteria are met per referenced objective criteria set

Primary coverage rationale: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation.

Policy refers clinicians to InterQual CP: Procedures, Hysterectomy +/- BSO or bilateral salpingectomy for detailed clinical coverage criteria.

Clinical guidance excerpts

Guidance and coverage-relevant statements from clinical societies and policy history

Society guidance on hysterectomy with BRCA risk-reducing surgery: Inclusion of hysterectomy with risk-reducing salpingo-oophorectomy for BRCA variant carriers should be individualized, taking into account risk factors for uterine cancer, other uterine pathology, and tamoxifen use.

SOGC: strong/moderate recommendation; insufficient data to routinely recommend hysterectomy to reduce papillary serous uterine cancer risk in BRCA1 carriers (conditional, low).

Hysterectomy for endometriosis/adenomyosis: Hysterectomy for endometriosis or adenomyosis with ovarian conservation can be an acceptable alternative.

Per SOGC Consensus Guidelines for Chronic Pelvic Pain (No. 164): hysterectomy can be indicated for severe symptoms after failure of other treatments when fertility is no longer desired.

Policy history note: Policy was retired effective 04/01/2026 and prior version language asserting hysterectomy as proven and medically necessary for chronic pelvic pain was removed in the 06/01/2025 revision.

See Policy History/Revision Information.

The following procedure and diagnosis codes are provided for reference only and do not by themselves determine coverage or payment. Listing of a code in this policy does not imply that the service described by the code is a covered or non‑covered health service; benefit coverage is determined by federal, state, or contractual requirements and applicable laws. Inclusion of a code in this document does not guarantee reimbursement and other policies or guidelines may apply.

The U.S. Food and Drug Administration advises that laparoscopic power morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy. Product labeling further contraindicates morcellator use for removal of uterine tissue containing suspected fibroids in patients who are peri‑ or post‑menopausal or when en bloc removal (for example via the vagina or mini‑laparotomy) is possible. Manufacturers’ labeling includes a boxed warning that morcellation may spread unsuspected cancer and adversely affect long‑term survival; this risk should be discussed with patients when considering use of these devices.

The role of prophylactic hysterectomy at the time of risk‑reducing salpingo‑oophorectomy (RRSO) in BRCA1/2 carriers remains controversial and should be individualized. Systematic reviews and meta‑analyses report an increased uterine cancer risk in some BRCA1/2 cohorts but do not uniformly support routine concurrent hysterectomy for all carriers. Consideration for concurrent hysterectomy may be reasonable in patients with tamoxifen exposure, those who may require hormone replacement therapy, or when uterine pathology is present; shared decision‑making and a careful risk–benefit assessment are recommended.

The policy language was revised to remove a prior statement that asserted hysterectomy is proven and medically necessary for the management of chronic pelvic pain. This change reflects updated coverage rationale and supporting evidence; clinicians should follow the current policy and cited guidance when considering hysterectomy for chronic pelvic pain.

Procedure and Device Coding

AbdominalCPT

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).

Laparoscopic / Vaginal / Laparoscopic-assisted vaginalCPT

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).
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).
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).
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).

Device classifications and warningsmixed

Class II

Laparoscopic power morcellator device classification (FDA)

Provider Actions & Authorization

Prior Authorization

InterQual Criteria Required

InterQual® criteria are required to determine medical necessity for hysterectomy (with or without bilateral salpingo-oophorectomy [BSO]). For medical necessity clinical coverage criteria, refer to InterQual CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy. Providers must include documentation demonstrating how the case meets applicable InterQual criteria when requesting authorization.

Authorization requests should reference the specific InterQual criteria met.
Clinical documentation supporting InterQual criteria (history, prior treatments, imaging, pathology, symptom severity) must be submitted.

Note

Applicable Codes (Informational)

The policy includes a list of procedure and diagnosis codes for reference only. Inclusion of a code does not imply a service is covered, guarantee reimbursement, or reflect applicability to every benefit plan.

Code lists are informational and may not be all inclusive.
Use member-specific benefit documents and payer guidance to determine coverage and billing applicability.

Background

A hysterectomy is a surgical procedure to remove the uterus and may include removal of the cervix, fallopian tubes, and/or ovaries depending on the indication and chosen approach. Approaches include abdominal, vaginal, laparoscopic (including total laparoscopic and laparoscopic‑assisted vaginal), and robotic‑assisted techniques. Common indications are benign conditions such as fibroids, endometriosis or adenomyosis, pelvic organ prolapse, and abnormal uterine bleeding; in BRCA variant carriers, concurrent removal of adnexal structures for cancer risk reduction (RRSO) and the decision about hysterectomy should be individualized based on uterine cancer risk, tamoxifen use, and other clinical factors.

Definitions

Total hysterectomy — definition

DefinitionRemoval of the entire uterus including the cervix.

Common indicationsBenign conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding may be treated with total hysterectomy.

ApproachesCan be performed vaginally, abdominally, laparoscopically, or with robotic assistance.

Supracervical (subtotal) hysterectomy — definition

DefinitionRemoval of the upper part of the uterus while leaving the cervix in place.

SynonymAlso called supracervical or partial hysterectomy.

Indications

Revision History

2026-04-01retirementLatest

Policy retired and Louisiana plan membership disenrolled on April 1, 2026.

2025-06-01revision

Coverage Rationale edited to remove language stating hysterectomy is proven and medically necessary for management of chronic pelvic pain; supporting information and references updated and previous version archived.