CurrentUnitedHealthcarePolicy CSNCT0572.08

Hysterectomy (for North Carolina Only)

This policy governs coverage and documentation expectations for hysterectomy procedures for UnitedHealthcare members in North Carolina, aligning clinical coverage criteria to the North Carolina Medicaid Clinical Coverage Policy 1E-1.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for North Carolina Only)

Policy CodePolicy CSNCT0572.08

Change TypeDocumentation requirements added

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionEnsure patient medical record includes relevant history, physical exam, and diagnostic test results and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews section added clarifying documentation requirements to support medical necessity.

NCapplicable state

~40procedure codes listed

black box referencedFDA morcellator info

Coverage Criteria

Medical necessity / Coverage linkage

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The policy highlights device-specific safety concerns for laparoscopic power morcellators. Product labeling includes an FDA black box warning advising that uterine tissue may contain unsuspected cancer and that morcellation can spread malignancy and adversely affect long‑term survival; this risk should be discussed with patients when considering morcellation during hysterectomy [[7]].

Manufacturer labeling and FDA guidance list explicit contraindications: morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy, and for removal of uterine tissue containing suspected fibroids in patients who are peri‑ or post‑menopausal or who are candidates for en bloc removal (for example, vaginally or via mini‑laparotomy) [[8]].

This policy does not duplicate detailed medical necessity criteria; for specific indications and determinations refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Obstetrics & Gynecology: 1E‑1, Hysterectomy, which governs clinical coverage decisions in this document's applicable jurisdiction [[2]].

Where the state policy defines a service as not medically necessary, that determination applies here; providers should follow the NC Medicaid Clinical Coverage Policy 1E‑1 for any explicit not medically necessary guidance or exclusions.

Procedure Codes and Coding Details

Abdominal 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; with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch).

Laparoscopic CPT CodesCPT

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.
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).

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.
58275	Vaginal hysterectomy, with total or partial vaginectomy.
58280	Vaginal hysterectomy, with total or partial vaginectomy; 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.

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Laparoscopic-Assisted Vaginal CPT CodesCPT

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).
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g.
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).

inv-08: Uterus weight thresholds used in CPT descriptors

CPT uterus-weight threshold250 g — distinguishes CPT descriptors for procedures coded '250 g or less' versus 'greater than 250 g'.

Applies to laparoscopic hysterectomy codesCodes 58541, 58542, 58570, 58571 are specified for uterus 250 g or less; codes 58543, 58544, 58572, 58573 are for uterus greater than 250 g.

Applies to vaginal hysterectomy codesVaginal CPTs include separate descriptors for uterus 250 g or less (e.g., 58260–58270 range) and for uterus greater than 250 g (e.g., 58290–58294).

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required when federal, state, or the member's contract requires it for the requested service. Providers should verify and obtain any required prior authorization before scheduling services to avoid claim denials or delays.

Prior authorization requirements follow applicable federal, state, or contractual benefit terms.
Codes listed in this policy are provided for reference and do not by themselves determine coverage or payment.

Documentation Required

Documentation Required to Support Medical Necessity

The patient's medical record must contain documentation that fully supports medical necessity for the requested services. Ensure records are legible, maintained in the patient's chart, and available upon request.

Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
Attach operative reports, imaging, pathology, and consult notes when applicable.

Denial Risk

Denial Risk — Inadequate Documentation

Lack of adequate documentation supporting medical necessity may lead to prior authorization denial or claim denial on review. Submit complete records at the time of request to reduce denial risk.

Incomplete history, missing exam findings, or absent diagnostic test results increase denial risk.
Failure to provide requested records upon audit may result in denial or recoupment.

Background

Hysterectomy is a surgical procedure to remove the uterus and may be performed by several approaches: abdominal, laparoscopic, vaginal, or laparoscopic‑assisted vaginal. Procedural selection depends on clinical indication, anatomy, and surgeon judgement, and relevant CPT descriptors distinguish techniques and uterine weight thresholds used for coding [[2]].

When performed laparoscopically, device considerations such as the use of a power morcellator carry specific safety guidance from the FDA; these device risks should inform procedural planning and shared decision making with the patient [[7]].

Definitions

inv-14: Hysterectomy procedure types — CPT group mapping

Total abdominal hysterectomy (CPT examples)Codes include 58150 and 58152 for total abdominal hysterectomy (corpus and cervix) with or without tube/ovary removal.

Supracervical (subtotal) abdominal hysterectomyCPT example: 58180 — supracervical abdominal hysterectomy (subtotal), with or without removal of tube(s) and/or ovary(s).

Laparoscopic hysterectomy codesIncludes supracervical and total laparoscopic procedures (e.g., 58541–58544, 58570–58573) with uterus-weight distinctions at 250 g.

Vaginal hysterectomy codesVaginal procedure group includes codes 58260–58294 covering uterus 250 g or less and greater than 250 g descriptors.

Laparoscopic-assisted vaginal hysterectomy codesCodes include 58550, 58552 (for uterus 250 g or less) and 58553, 58554 (for uterus greater than 250 g).

inv-15: Laparoscopic power morcellator — device definition and FDA warnings/contraindications summary

Device definitionLaparoscopic power morcellator: a Class II medical device used during laparoscopic surgery, commonly in hysterectomy procedures.

FDA boxed warning (summary)Product labeling recommends a prominent black box warning that uterine tissue may contain unsuspected cancer and use during fibroid surgery may spread cancer and decrease long-term survival; this risk should be discussed with patients.

Contraindications (summary)Morcellators are contraindicated when tissue to be morcellated is known or suspected to contain malignancy, and contraindicated for removal of uterine tissue with suspected fibroids in peri- or post-menopausal patients or candidates for en bloc removal.

Reference guidance linksManufacturer labeling and FDA resources cited for additional details: FDA device pages and guidance documents (links provided in source).