DraftUnitedHealthcarePolicy CS196NE.I

Hysterectomy (for Nebraska Only)

Nebraska-specific UnitedHealthcare medical policy governing coverage criteria and clinical considerations for hysterectomy procedures for members in Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Nebraska Only)

Policy CodePolicy CS196NE.I

Change TypeText revisions and additions

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain and provide medical record documentation that fully supports medical necessity, including history, exam, and diagnostic results, when requesting coverage or prior authorization.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction to 'refer to the Nebraska Department of Health and Human Services, Code 471-18-006.01: Surgical Procedures and the Nebraska Department of Health and Human Services, Code 471-18-005.07: Hysterectomies for information on hysterectomies' with 'refer to the Nebraska Department of Health and Human Services, Code 471-18-006.01: Surgical Procedures and the Nebraska Department of Health and Human Services, Code 471-18-005.07: Hysterectomies for coverage criteria'.

Added language clarifying medical records documentation that may be required to assess whether the member meets clinical criteria for coverage and that documentation must support medical necessity.

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

NebraskaState-specific

InterQualClinical source

BRCACovered indication

Morcellator warningDevice safety noted

Coverage Criteria

Coverage criteria overview

Coverage follows Nebraska state codes and InterQual clinical criteria; specific medical necessity must be met.

State-specific statutory criteria: Refer to Nebraska Department of Health and Human Services, Code 471-18-006.01 (Surgical Procedures) and 471-18-005.07 (Hysterectomies) for state coverage criteria.

Legal/state criteria source

InterQual clinical criteria: Medical necessity for hysterectomy is determined per InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy; refer to the InterQual criteria for specific clinical indications.

InterQual referenced for clinical coverage

BRCA1/2 indication: Hysterectomy is proven and medically necessary for management of individuals with a BRCA1 or BRCA2 gene mutation.

Document cites BRCA indication as covered

Covered when guideline-based clinical indications are met

Guideline-based considerations and indications referenced in the policy include:

Guideline considerations for RRSO and concurrent hysterectomy: Discuss risks and benefits of concurrent hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO) for individuals with a BRCA1/2 P/LP variant; timing of RRSO is individualized (typically 35–40 years for BRCA1, 40–45 years for BRCA2) per NCCN guidance.

Source: NCCN

Tamoxifen and atypical endometrial hyperplasia: Women taking tamoxifen should be informed about increased risks of endometrial proliferation, hyperplasia, and cancer; postmenopausal tamoxifen users should be closely monitored, and if atypical endometrial hyperplasia develops and tamoxifen is continued with accepted risks, hysterectomy should be considered.

Source: ACOG Committee Opinion #601

Endometriosis or chronic pelvic pain (including adenomyosis): Hysterectomy may be acceptable for endometriosis or adenomyosis with ovarian conservation and can be indicated for severe symptoms after failure of other treatments when fertility is no longer desired.

Sources: SOGC; NICE recognizes chronic pelvic pain/endometriosis guidance

Coverage for hysterectomy in Nebraska is governed by Nebraska Department of Health and Human Services statutory criteria and by clinical review using InterQual procedure criteria. Medical necessity must be established per the referenced state codes (see Nebraska codes cited in the policy) and the InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy criteria; the InterQual criteria define the specific clinical indications that justify coverage.

The policy includes device safety language regarding laparoscopic power morcellators. The FDA warns that uterine tissue may contain unsuspected cancer and that morcellation during fibroid surgery may spread malignant tissue and negatively affect long-term survival. Product labeling includes a boxed warning and specific contraindications: morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy, and they are contraindicated for removal of uterine tissue containing suspected fibroids in peri- or postmenopausal patients or when en bloc removal is feasible (for example via the vagina or mini-laparotomy).

The policy notes there are insufficient data to routinely recommend prophylactic hysterectomy solely to reduce the risk of papillary serous uterine cancer in individuals with a BRCA1 pathogenic or likely pathogenic variant; decisions regarding inclusion of hysterectomy with risk‑reducing salpingo-oophorectomy (RRSO) should be individualized based on uterine cancer risk, other uterine pathology, and factors such as tamoxifen use.

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 — CPT codes are specified separately for uterus 250 g or less versus greater than 250 g (see laparoscopic, vaginal, and laparoscopic-assisted vaginal codes).

Coding impactSelect CPT code variant based on documented uterine weight (≤250 g or >250 g).

Relevant code groupsLaparoscopic codes (58541–58544, 58570–58573) and vaginal/assisted vaginal codes (58260–58294, 58550–58554) include the weight distinction.

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Applicable CPT Codes

Prior authorization requirements apply per plan and state rules. Prior authorization may be required before scheduling hysterectomy procedures; verify member benefits and obtain approval when required.

Applicable CPT codes (examples, not all inclusive): 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58550, 58552, 58553, 58554

Documentation Required

Medical Records Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This includes, but is not limited to, relevant medical history, physical examination findings, diagnostic test results, imaging, pathology, and documentation of prior treatments and responses.

Background

A hysterectomy is a surgical procedure to remove the uterus and may include removal of the ovaries and fallopian tubes. It is employed to treat benign gynecologic conditions including uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding. Surgical approaches commonly used are vaginal, abdominal, laparoscopic (including total laparoscopic and laparoscopic-assisted vaginal), and robotic-assisted techniques.

Definitions

Total hysterectomy

DefinitionTotal hysterectomy — removal of the entire uterus, including the cervix.

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

Common indicationsUsed to treat benign conditions such as fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding.

Supracervical hysterectomy

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

Coding examplesCPT codes include supracervical abdominal (58180) and laparoscopic supracervical (58541–58544) variants.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Nebraska Only)

Policy CodePolicy CS196NE.I

Change TypeText revisions and additions

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain and provide medical record documentation that fully supports medical necessity, including history, exam, and diagnostic results, when requesting coverage or prior authorization.

SourceLink

On This Page

Documentation must be legible and maintained in the patient's medical record.

Records should be made available upon request for review.

Include prior conservative therapies tried, duration, and clinical response.

Denial Risk

Documentation May Be Required — Impact on Coverage Determinations

Medical records documentation may be requested to assess whether the member meets the clinical criteria for coverage. Submission of records does not guarantee coverage. Lack of sufficient documentation to support medical necessity may result in denial or inability to assess coverage.

Failure to provide complete medical records that substantiate medical necessity may result in denial of the requested service.
When prior authorization is requested, submit all relevant records contemporaneously to expedite review.

Step Therapy

Therapy Sequencing for Chronic Pelvic Pain/Endometriosis

Hysterectomy for chronic pelvic pain, endometriosis, or adenomyosis should generally be considered only after other appropriate medical and minimally invasive treatments have failed and when fertility is no longer desired. Document prior therapies, their duration, and rationale for proceeding to hysterectomy.

Hysterectomy can be indicated in the presence of severe symptoms with failure of other treatment when fertility is no longer desired.
Document trials of hormonal therapy, conservative surgical procedures, analgesics, and other relevant interventions.

Note

State-Specific Coverage References

Providers should verify state-specific coverage criteria when applicable (e.g., Nebraska DHHS Codes 471-18-006.01 and 471-18-005.07) and include citations or excerpts of those criteria in submitted documentation when relevant.

Refer to Nebraska Department of Health and Human Services Codes 471-18-006.01 and 471-18-005.07 for state-specific hysterectomy coverage criteria.
Ensure documentation aligns with any state-mandated criteria prior to authorization submission.

Clinical noteAlso referred to as subtotal hysterectomy; ovary/tube removal may be performed concurrently as indicated.

Vaginal hysterectomy

DefinitionVaginal hysterectomy — uterus removed through the vagina.

Coding distinctionVaginal hysterectomy CPT codes differentiate uterus 250 g or less versus greater than 250 g (e.g., 58260 vs 58290 and related code set).

Appropriate useMay be performed with or without removal of tubes/ovaries and with repairs (e.g., enterocele) as coded.

Abdominal hysterectomy

DefinitionAbdominal hysterectomy — uterus removed through an incision in the lower abdomen.

CPT examplesTotal abdominal hysterectomy codes include 58150 and 58152; supracervical abdominal hysterectomy is 58180.

Clinical considerationsMay be chosen for large uteri, extensive adhesions, or when en bloc removal is indicated.

Total laparoscopic hysterectomy (TLH)

DefinitionTotal laparoscopic hysterectomy (TLH) — uterus removed in small pieces through laparoscopic incisions or through the vagina.

Coding examplesLaparoscopic total hysterectomy codes specify uterine weight (e.g., 58570–58573) and may include concurrent tube/ovary removal.

Approach noteUses a laparoscope with additional small abdominal incisions for instruments; may be performed with robotic assistance.

RRSO (risk-reducing salpingo-oophorectomy)

DefinitionRisk-reducing salpingo-oophorectomy (RRSO) — removal of fallopian tubes and ovaries performed to reduce ovarian cancer risk, often discussed with consideration of concurrent hysterectomy for BRCA carriers.

Timing recommendationNCCN: typically perform RRSO between ages 35–40 for BRCA1 carriers and between 40–45 for BRCA2 carriers unless family history indicates earlier intervention.

Counseling pointNCCN recommends discussing risks and benefits of concurrent hysterectomy at the time of RRSO for individuals with a BRCA1/2 P/LP variant.

Laparoscopic power morcellator warning

Primary safety warningLaparoscopic power morcellators may spread unsuspected malignant uterine tissue and reduce long-term survival; this risk should be communicated to patients.

ContraindicationsContraindicated when the tissue to be morcellated is known or suspected to contain malignancy, and in peri- or postmenopausal patients or candidates for en bloc removal.

Regulatory referencesProduct labeling includes a prominent boxed warning and contraindications; FDA resources and guidance links are provided in the policy for further details.