ModifiedUnitedHealthcarePolicy CS196NM.C

Hysterectomy (for New Mexico Only)

This policy defines clinical coverage criteria, documentation, and applicable coding for hysterectomy services for UnitedHealthcare members in New Mexico; it affects providers requesting authorization and claims for hysterectomy procedures in that state.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for New Mexico Only)

Policy CodePolicy CS196NM.C

Change TypeAdded state-specific NMAC referenceclarified documentation requirements

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProvide complete medical record documentation (history, exam, and pertinent test results) to support medical necessity and check plan/state requirements before requesting authorization.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the New Mexico Administrative Code (NMAC), Title 8, Chapter 310, Part 2: General Benefit Description for coverage criteria.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria for coverage.

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

New MexicoPolicy applies only to

IncludedBRCA mutation listed as indication

InterQualMedical necessity criteria source

NMAC

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

State-specific code reference added

CS196NM.BPrevious version archived

Coverage Criteria

Medical necessity coverage criteria

Covered when meeting InterQual clinical criteria or specific indications:

Primary coverage pathways: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation. For other indications, hysterectomy is medically necessary in certain circumstances per InterQual CP: Procedures, Hysterectomy ± BSO or bilateral salpingectomy.

Refer to InterQual criteria for detailed clinical requirements.

Clinical Considerations for Hysterectomy — Consider when ALL apply

Consider hysterectomy when ALL of the following clinical considerations apply (per cited societies):

BRCA carriers and RRSO concurrent hysterectomy discussion: Patients with BRCA1/2 pathogenic or likely pathogenic variants should discuss risks and benefits of concurrent hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO); timing of RRSO is generally age 35–40 years for BRCA1 and 40–45 years for BRCA2.

NCCN guidance recommends individualized discussion

Tamoxifen and endometrial pathology: Women taking tamoxifen should be informed about risks of endometrial proliferation, hyperplasia, and cancer; if atypical endometrial hyperplasia develops and tamoxifen is to be continued, hysterectomy should be considered.

ACOG Committee Opinion #601

Endometriosis/adenomyosis/chronic pelvic pain: 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; chronic pelvic pain considerations (e.g., ≥6 months) support individualized use.

SOGC and NICE guidance; consider non-surgical alternatives before hysterectomy

Device safety considerations: Avoid use of laparoscopic power morcellators when tissue to be morcellated is known or suspected to contain malignancy or in peri-/postmenopausal patients for removal of fibroid-containing uterine tissue; inform patients about the risk of spreading unsuspected cancer.

FDA black box warning and contraindications

Coverage determinations for hysterectomy services in New Mexico are governed by the New Mexico Administrative Code (NMAC). Refer specifically to NMAC Title 8, Chapter 310, Part 2: General Benefit Description when applying state-specific coverage rules or reconciling plan provisions with this policy.

The use of laparoscopic power morcellators is contraindicated when the tissue to be morcellated is known or suspected to contain malignancy. Additionally, morcellation with power devices is contraindicated for removal of uterine tissue containing suspected fibroids in peri- or postmenopausal patients, and when en bloc removal (for example via the vagina or mini‑laparotomy) is indicated. Providers should counsel patients about the risk of disseminating unsuspected cancer with power morcellation and follow FDA guidance.

Routine prophylactic hysterectomy at the time of risk‑reducing salpingo‑oophorectomy (RRSO) for BRCA1/2 carriers is not universally recommended. Evidence is mixed: some analyses show a small reduction in future uterine cancer risk and possible incremental survival benefit in selected patients, especially those with tamoxifen exposure or who may require estrogen therapy, but multiple reviews conclude that prophylactic hysterectomy should be considered on an individualized, case‑by‑case basis rather than performed routinely.

Clinical guidance recommends discussing risks and benefits of concurrent hysterectomy when planning RRSO. For BRCA carriers, timing of RRSO is typically individualized (commonly age 35–40 for BRCA1 and 40–45 for BRCA2), and decisions about adding hysterectomy should factor in uterine cancer risk, tamoxifen history, HRT plans, and patient preferences.

Major society guidance does not universally mandate prophylactic hysterectomy with RRSO. Recommendations emphasize individualized decision‑making: SOGC and NCCN advise assessing uterine cancer risk factors (including tamoxifen use) and discussing the option with BRCA1/2 carriers; systematic reviews and meta‑analyses report conflicting evidence and generally conclude that routine prophylactic hysterectomy is not clearly supported by current data.

Coding

Laparoscopic and 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).
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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Notesmixed

CPT	CPT is a registered trademark of the American Medical Association (reference note).

No explicit billing codes in this document portionmixed

No codes listed

Uterus weight threshold — 250 g distinction for CPT

Uterus weight threshold250 g (several CPT codes distinguish uterus ≤250 g vs >250 g)

Codes specifying ≤250 gCPT codes: 58541, 58542, 58570, 58571, 58550, 58552, 58260-58270 group reference indicate 'for uterus 250 g or less'

Codes specifying >250 gCPT codes: 58543, 58544, 58572, 58573, 58553, 58554, 58290-58294 group reference indicate 'for uterus greater than 250 g'

Typical age for RRSO (BRCA1/BRCA2)

Typical age for RRSO — BRCA1Typically between 35 and 40 years of age for carriers of a BRCA1 pathogenic/likely pathogenic variant.

Typical age for RRSO — BRCA2

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Applicable Codes

Prior authorization requirements and applicable billing/coding should be verified prior to scheduling. Applicable procedure and diagnosis codes are listed elsewhere in this policy and are for reference only; inclusion does not guarantee coverage or reimbursement.

Check plan-specific prior authorization rules and any state or federal mandate that may require or waive prior authorization.
If using InterQual or other third‑party criteria, include the decision support reference in the authorization request.

Note

Benefit Plan Governing Documents

Benefit coverage is governed by the member’s federal, state, or contractual plan documents. In cases of conflict between this Medical Policy and the member’s plan documents or applicable law, the federal/state/contractual requirements govern.

Before rendering services, confirm plan-specific benefits, limitations, exclusions, and any state‑specific mandates (for example, New Mexico Administrative Code where applicable).

Background

A hysterectomy is a surgical procedure to remove the uterus and may include concurrent removal of the fallopian tubes and ovaries. Common surgical approaches include vaginal, abdominal, laparoscopic (including total laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy), and robotic‑assisted techniques. Indications for hysterectomy in benign disease include symptomatic fibroids, endometriosis/adenomyosis, pelvic organ prolapse, and abnormal uterine bleeding; for BRCA1/2 carriers, hysterectomy may be considered in specific circumstances after individualized risk‑benefit discussion.

Definitions

Total hysterectomy definition

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

IncludesMay include removal of ovaries and fallopian tubes depending on clinical indication.

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

Supracervical (partial) hysterectomy definition

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

SynonymAlso called subtotal hysterectomy.

Relevant CPT examples

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for New Mexico Only)

Policy CodePolicy CS196NM.C

Change TypeAdded state-specific NMAC referenceclarified documentation requirements

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProvide complete medical record documentation (history, exam, and pertinent test results) to support medical necessity and check plan/state requirements before requesting authorization.

SourceLink

On This Page

Typically between 40 and 45 years of age for carriers of a BRCA2 pathogenic/likely pathogenic variant.

Decision factorsTiming may be individualized based on family history (age at diagnosis) and discussion of risks/benefits of concurrent hysterectomy at time of RRSO.

This policy is informational and does not replace benefits language in the member’s contract.

Documentation Required

Required Medical Record Documentation

Medical record documentation must fully support the medical necessity of the requested service. Lack of adequate documentation may result in denial or delay of coverage.

Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
Chart notes should be legible, contemporaneous, and available upon request; failure to provide requested records may lead to denial.
Document prior conservative/non‑surgical therapies and objective measures of symptom severity when clinically applicable.

Denial Risk

Documentation / Regulatory Denial Risk

Coverage decisions may be denied or rescinded if medical records do not substantiate that the member meets the clinical criteria for the requested service.

Denials may be issued when documentation is incomplete, absent, or inconsistent with the clinical criteria cited in this policy or referenced InterQual criteria.
Provide complete records with the initial submission to reduce regulatory and documentation‑related denial risk.

Note

Non‑surgical Alternatives for Chronic Pelvic Pain / Adenomyosis

Non‑surgical alternatives for management of chronic pelvic pain and adenomyosis should be considered and documented prior to surgical interventions when clinically appropriate.

Conservative options include medical therapies such as levonorgestrel‑releasing intrauterine system (LNG‑IUS), dienogest, combined oral contraceptives, GnRH analogs, and other pharmacologic treatments.
Document prior trials, duration, response, and reasons for discontinuation or failure of non‑surgical therapies in the medical record.
When evidence supports non‑surgical management (e.g., symptom control or quality‑of‑life improvement with LNG‑IUS), clearly justify the need for surgical treatment in the record.

CPT 58180 (supracervical abdominal hysterectomy); laparoscopic supracervical codes include 58541/58542 (≤250 g) and 58543/58544 (>250 g).

Total laparoscopic hysterectomy (TLH) definition

DefinitionTotal laparoscopic hysterectomy (TLH): laparoscopic removal of the uterus, typically removed in small pieces through abdominal incisions or through the vagina.

Procedure noteUses a laparoscope inserted via small abdominal incisions to visualize and guide removal; additional small incisions accommodate instruments.

Coding distinctionLaparoscopic total hysterectomy CPT codes distinguish uterus weight (e.g., 58570/58571 for ≤250 g; 58572/58573 for >250 g).

RRSO definition (risk-reducing salpingo-oophorectomy)

DefinitionRisk-reducing salpingo-oophorectomy (RRSO): surgical removal of the fallopian tubes and ovaries to reduce risk of ovarian cancer, often discussed for BRCA1/2 carriers.

Concurrent hysterectomy discussionNCCN recommends discussing risks and benefits of concurrent hysterectomy at the time of RRSO for BRCA1/2 P/LP variant carriers; decision individualized per SOGC guidance.

Timing guidanceNCCN timing: BRCA1 typically 35–40 years; BRCA2 typically 40–45 years (unless family history warrants earlier intervention).

Laparoscopic power morcellator definition and FDA warning

DefinitionLaparoscopic power morcellator: a Class II surgical device used to morcellate (fragment) uterine tissue for removal during minimally invasive procedures.

FDA safety warningUse may spread unsuspected uterine cancer and decrease long-term survival; patients should be informed of this risk.

ContraindicationsContraindicated when the tissue to be morcellated is known or suspected to contain malignancy, and contraindicated for removal of fibroid-containing uterine tissue in peri- or post-menopausal patients; consider en bloc removal instead.