RetiredUnitedHealthcarePolicy CS196LA.C

Hysterectomy (for Louisiana Only)

Policy governing medical necessity and coding guidance for hysterectomy procedures for UnitedHealthcare members in Louisiana; includes indications, clinical background, and applicable procedure codes. Affects providers and claim reviewers for Louisiana only.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Louisiana Only)

Policy CodePolicy CS196LA.C

Change TypeRetirement and substantive revision (06/01/2025retired 04/01/2026)

Effective DateJune 1, 2025

Next Review DateN/A

Key ActionRefer to InterQual CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy for medical necessity clinical coverage criteria before seeking authorization.

SourceLink

POLICY UPDATE CHANGES

Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

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

Louisiana-onlyjurisdiction

06/01/2025most recent substantive revision

04/01/2026policy retirement date

BRCA1/2explicit covered indication

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Coverage Criteria and Clinical Indications

BRCA1/BRCA2 indication

Covered when specific clinical indications are met per referenced criteria.

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

Refer to InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy for detailed clinical coverage criteria.

Chronic pelvic pain / adenomyosis

Clinical considerations for chronic pelvic pain, adenomyosis, and endometriosis.

Non-surgical alternatives: Levonorgestrel-releasing intrauterine system (LNG-IUS) and medical agents (e.g., dienogest) have evidence of symptom control and may be considered prior to hysterectomy when appropriate.

Randomized trials and RCTs report LNG-IUS and dienogest reduce bleeding and pelvic pain and may improve quality-of-life measures; hysterectomy may be reserved for severe symptoms or failed medical management.

Society guidance excerpts

Guidance excerpts and relevant policy history to inform individualized decisions.

BRCA carriers and hysterectomy: Decision to include hysterectomy with risk-reducing salpingo-oophorectomy (RRSO) should be individualized, taking into account uterine cancer risk factors, other uterine pathology, and tamoxifen use.

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

Chronic pelvic pain / endometriosis / adenomyosis: Hysterectomy with ovarian conservation can be an acceptable option for endometriosis or adenomyosis and may be indicated for severe symptoms after failure of other treatments when fertility is no longer desired.

Consensus Guidelines for Management of Chronic Pelvic Pain support hysterectomy as an option after other therapies fail.

Policy history note: Language stating hysterectomy was proven and medically necessary for management of chronic pelvic pain was removed from the coverage rationale on 06/01/2025; policy retired for Louisiana effective 04/01/2026.

Operational and revision history should be considered when applying coverage criteria.

The policy notes that laparoscopic power morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy. Product labeling includes a boxed warning that uterine tissue may contain unsuspected cancer and that morcellation can spread malignancy and worsen long-term outcomes; this information should be discussed with patients prior to use.

Manufacturer labeling and FDA guidance further specify that laparoscopic power morcellators are contraindicated 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 feasible; use contrary to these device contraindications may prompt safety concerns or denial.

Evidence reviews and meta-analyses summarized in the policy indicate that the addition of a prophylactic hysterectomy at the time of risk‑reducing bilateral salpingo‑oophorectomy (RRSO) for BRCA1/2 carriers remains controversial. Some studies show an increased uterine cancer risk in BRCA carriers and potential benefit in patients with tamoxifen exposure, but overall guidance supports individualized decision‑making rather than a routine recommendation for concurrent hysterectomy.

The policy was updated on 06/01/2025 to remove prior language asserting that hysterectomy is proven and medically necessary for the management of chronic pelvic pain; the revision clarified that hysterectomy may be an option after failure of other therapies but is not universally established as medically necessary.

Procedure Codes and Coding Notes

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 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).

LaparoscopicCPT

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.
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).

Vaginal; Laparoscopic-Assisted VaginalCPT

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.
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).
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).

Uterus weight threshold — 250 g differentiator for some CPT codes

Uterus weight threshold250 g — several CPT codes differentiate procedures for uterus 250 g or less versus greater than 250 g (examples: 58541/58570 and 58543/58572; 58260/58550 and 58290/58553)

Codes specifying <=250 gExamples include 58541 (laparoscopic supracervical hysterectomy, uterus 250 g or less), 58570 (laparoscopic total hysterectomy, uterus 250 g or less), 58260 (vaginal hysterectomy, uterus 250 g or less)

Codes specifying >250 gExamples include 58543 (laparoscopic supracervical hysterectomy, uterus greater than 250 g), 58572 (laparoscopic total hysterectomy, uterus greater than 250 g), 58290 (vaginal hysterectomy, uterus greater than 250 g)

What Providers Must Do / Watch For

Documentation Required

Prior Authorization / Documentation & Billing — Key Points

The following provider actions and watch‑fors apply when managing and billing for hysterectomy procedures. This section is informational and does not replace plan‑specific benefit, federal, state or contractual coverage requirements.

Billing Rule

Coding listing disclaimer

Coding lists in this policy are provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non‑covered health service, guarantee reimbursement, or guarantee claim payment. Benefit coverage is determined by applicable federal, state, and contractual requirements. Verify member benefits and plan contract language prior to rendering services.

Listing of a code does not imply coverage or right to reimbursement.
Inclusion of codes is informational only; check plan contract for coverage determination.

Clinical Background

A hysterectomy is a surgical procedure to remove the uterus and may include removal of the ovaries and fallopian tubes. Surgical approaches include abdominal, vaginal, laparoscopic (including laparoscopic‑assisted vaginal and total laparoscopic hysterectomy), and robotic techniques. CPT code groupings in the policy reflect these approaches and differentiate procedures in some cases by uterus weight threshold of 250 g.

Definitions and Procedure Types

Total hysterectomy

DefinitionRemoval of the entire uterus including the cervix.

Common approachesMay be performed via vaginal, abdominal, laparoscopic, laparoscopic-assisted vaginal, or robotic routes.

Indications (examples)Benign conditions such as fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding may be treated with total hysterectomy.

Supracervical (partial) hysterectomy

DefinitionRemoval of the upper part of the uterus while leaving the cervix in place (supracervical or partial hysterectomy).

Surgical approachCan be performed abdominally, vaginally, or laparoscopically (CPT examples include supracervical codes such as 58541/58543).

Policy Updates and Retirement

2026-04-01retirementLatest

Policy retired and Louisiana plan membership disenrolled effective Apr. 1, 2026.

2025-06-01substantive_revision

Removed language stating hysterectomy is proven and medically necessary for management of chronic pelvic pain; updated clinical evidence and references; archived previous policy version CS196LA.B.