CurrentUnitedHealthcarePolicy CS196NE.I

Hysterectomy (for Nebraska Only)

UnitedHealthcare medical policy applicable only to Nebraska members describing coverage criteria, referenced Nebraska DHHS codes (471-18-006.01 and 471-18-005.07), InterQual criteria for medical necessity, applicable CPT codes, documentation requirements, clinical background (BRCA mutations, chronic pelvic pain, tamoxifen), and policy history effective March 1, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Nebraska Only)

Policy CodePolicy CS196NE.I

Change TypeState-specific wordingdocumentation addedevidence updated

Effective DateMar 1, 2026

Next Review Date

Key ActionEnsure medical record includes relevant medical history, physical examination, and results of pertinent diagnostic tests/procedures; documentation must be legible, maintained in the record, and available upon request.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction wording to refer to Nebraska DHHS codes for coverage criteria (471-18-006.01 and 471-18-005.07).

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

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

Nebraska-onlyGeographic scope

InterQualClinical criteria source

BRCA1/2Explicit covered indication

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Coverage Summary

Scope: UnitedHealthcare medical policy applicable only to Nebraska members describing coverage criteria for hysterectomy (Policy Number CS196NE.I). Coverage stance: mixed; coverage determinations reference state DHHS codes and InterQual clinical criteria. Geographic scope: Nebraska-only (policy applies only to the State of Nebraska). Clinical criteria source: InterQual CP: Procedures, Hysterectomy, +/- BSO or Bilateral Salpingectomy referenced for medical necessity determinations. Explicit covered indication: Hysterectomy is proven and medically necessary for individuals with BRCA1 or BRCA2 gene mutation. Effective date and last review: March 1, 2026.

Key facts

Policy numberCS196NE.I

Geographic scopeNebraska-only

Clinical criteria sourceInterQual

Effective date2026-03-01

StatusCURRENT

Medical-Necessity Criteria

Documentation Requirement for Medical Necessity Reviews

Medical records must fully support medical necessity.

Medical Records Documentation Used for Reviews

Coverage determined by federal/state/contractual requirements: Benefit coverage for health services is determined by the federal, state, or contractual requirements, and applicable laws that may require coverage for a specific service
Medical records may be required: Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the services requested
Record must fully support medical necessity: The patient's medical record must contain documentation that fully supports the medical necessity for the requested services

Coding

Applicable CPT codes (hysterectomy procedures listed for reference)CPT

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)
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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Provider Actions

Documentation Required

Medical record documentation required for medical necessity review

Medical records must fully support the medical necessity for the requested hysterectomy. Documentation should be clear and complete, and available if requested for review.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Records must be legible and maintained in the patient's medical record
Records must be made available upon request

Prior Authorization

Reference to InterQual criteria for medical necessity determinations

InterQual CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy is referenced and should be used to determine whether a hysterectomy meets the medical necessity clinical coverage criteria.

Background and Evidence

Background: A hysterectomy is a surgical procedure to remove the uterus and sometimes the ovaries and fallopian tubes. Types include total and supracervical (subtotal) hysterectomy and can be performed vaginally, abdominally, laparoscopically, or with robotic assistance. Benign conditions that may be treated with hysterectomy include uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding. Evidence regarding BRCA1/2 carriers is mixed: systematic reviews and cohort studies report a two- to three-fold increased risk of endometrial cancer in some BRCA1/2 carriers but do not uniformly support routine prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy; tamoxifen use is associated with a two- to three-fold increase in uterine malignancies, and this may make hysterectomy at the time of RRSO an option. For adenomyosis and chronic pelvic pain, non-surgical alternatives such as the levonorgestrel-releasing intrauterine system (LNG-IUS) have shown benefit for bleeding and pelvic pain and may be a promising alternative to hysterectomy in some patients.

Evidence summary

Systematic reviews/meta-analyses referencedGasparri 2022; Nahshon 2021; Matanes 2020; de Jonge 2021; Kitson 2020

Guideline referencesACOG Practice Bulletin #793; ACOG Committee Opinion #601; NCCN Genetic/Familial High-Risk Assessment v1.2026; NICE guidelines; SOGC guidance

Definitions

Definitions: Hysterectomy — surgical removal of the uterus; may include removal of ovaries and fallopian tubes; types include total, supracervical (subtotal), vaginal, abdominal, laparoscopic, and robotic-assisted approaches. RRSO / RRBSO — risk-reducing salpingo-oophorectomy / risk-reducing bilateral salpingo-oophorectomy: removal of fallopian tubes and ovaries to reduce cancer risk.

Revision History

03/01/2026rewordingLatest

Reworded state-specific referral guidance to direct readers to Nebraska DHHS codes 'for coverage criteria' (Code 471-18-006.01 and Code 471-18-005.07).

03/01/2026additionLatest

Added explicit medical records documentation requirements: benefit coverage is determined by federal/state/contractual requirements; medical records may be required to assess coverage; patient's record must fully support medical necessity and include relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the record, and made available upon request.