ModifiedUnitedHealthcarePolicy CS196OH.E

Hysterectomy (for Ohio Only)

State-specific UnitedHealthcare medical policy for hysterectomy in Ohio, defining indications, applicable coding, and clinical guidance for providers and payers in Ohio Medicaid/plan populations.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Ohio Only)

Policy CodePolicy CS196OH.E

Change TypeRemoval of prior language on chronic pelvic painreferences updated

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionDetermine medical necessity using the InterQual CP: Procedures, Hysterectomy (+/- BSO or bilateral salpingectomy) and document adherence to Ohio Administrative Code requirements.

SourceLink

POLICY UPDATE CHANGES

Related Policies added reference link to the Medical Policy titled Gender Dysphoria Treatment (for Ohio Only).

Coverage Rationale language indicating hysterectomy is proven and medically necessary for management of chronic pelvic pain was removed.

Supporting Information updated Clinical Evidence and References sections to reflect the most current information.

Ohio-onlyjurisdiction

InterQual referencedclinical criteria

BRCA1/2 discussedBRCA consideration

Multiple CPT codes

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Coverage Criteria for Hysterectomy (Ohio Only)

General medical necessity

Covered when supported by InterQual criteria and state rules.

InterQual and State Rule Requirement: Hysterectomy is considered proven and medically necessary when clinical coverage criteria in the InterQual CP: Procedures, Hysterectomy (+/- BSO or bilateral salpingectomy) are met and when consistent with Ohio Administrative Code provisions.

Refer to InterQual for detailed clinical criteria and to Ohio Administrative Code 5160-21-02.2 for sterilization/hysterectomy specifics

BRCA1/2 and prophylactic hysterectomy

Prophylactic hysterectomy in BRCA1/2 carriers.

BRCA-related consideration: Hysterectomy may be considered in individuals with BRCA1 or BRCA2 pathogenic variants, particularly in the context of risk-reducing salpingo-oophorectomy (RRSO) or tamoxifen exposure; decisions should be individualized following guideline discussion (NCCN) and risk–benefit assessment.

Literature is mixed; prophylactic hysterectomy may be reasonable for select patients (e.g., tamoxifen users) and requires shared decision-making

Conservative management considerations

Chronic pelvic pain / adenomyosis management.

Conservative therapies before hysterectomy: Randomized trials show levonorgestrel-releasing intrauterine system (LNG-IUS) and medical therapies (e.g., dienogest, GnRH analogs) can improve bleeding, pelvic pain, and quality of life and may be alternatives to hysterectomy for adenomyosis or menorrhagia; consider conservative options where appropriate prior to hysterectomy.

Some trials reported LNG-IUS superior in psychosocial QOL domains compared to hysterectomy in selected studies

Clinical guidance excerpts

Clinical guidance excerpts relevant to hysterectomy decisions.

BRCA-related RRSO and hysterectomy timing: Patients with known BRCA1/2 pathogenic variants should discuss risks and benefits of concurrent hysterectomy at time of RRSO; RRSO is typically recommended between 35–40 years for BRCA1 and 40–45 years for BRCA2 unless family history warrants earlier intervention.age ranges

From NCCN clinical guidelines (v3.2024)

Laparoscopic hysterectomy for endometrial cancer: Evidence supports use of laparoscopic hysterectomy (including total and laparoscopically assisted vaginal hysterectomy) for endometrial cancer.

From NICE IPG356

Hysterectomy for endometriosis/chronic pelvic pain: 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.pelvic pain >= 6 months as potential sign of endometriosis

The list of procedure and diagnosis codes provided in this policy is for reference only. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by applicable federal, state, or contractual requirements and laws and other policies; inclusion of a code does not guarantee reimbursement or claim payment.

A laparoscopic power morcellator is a Class II medical device used during laparoscopic surgery to morcellate uterine tissue. Product labeling includes a prominent black box warning and contraindications: morcellators are contraindicated when the tissue to be morcellated is known or suspected to contain malignancy, and 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 an option. These device contraindications should be considered when planning procedures.

This policy was revised effective 04/01/2025 to remove prior language that stated hysterectomy is proven and medically necessary for the management of chronic pelvic pain. The removal of that statement means the policy no longer asserts hysterectomy as an established coverage position for chronic pelvic pain without application of the stated clinical criteria and guidance.

Procedure and Device Coding

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 (corpus and cervix); with colpo-urethrocystopexy (e.g , Marshall-Marchetti-Krantz, Burch).

Laparoscopic / Laparoscopic-assisted 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).
58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less.

1–10 of 13

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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).
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-...).
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.

Device classificationmixed

Class II

Laparoscopic power morcellator device classification (FDA).

Provider Actions, Documentation, and Decision Support

Documentation Required

Medical necessity evaluation and documentation

Requests for hysterectomy and related procedures will be evaluated for medical necessity using InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy. For Ohio Medicaid members, requests for services that are stated as unproven or for which there is a coverage or quantity limit will be reviewed in accordance with the Ohio Administrative Code (OAC) 5160 series. Documentation submitted should support how the InterQual criteria are met and include relevant clinical history, prior treatments, diagnostic findings, and fertility considerations as applicable.

Evaluate medical necessity using InterQual criteria; include clinical documentation showing criteria met
For Ohio Medicaid, apply OAC 5160 requirements when services are unproven or limited
Document prior treatments, diagnostic tests, and fertility desires

Note

Benefit verification and governing requirements

In determining coverage, UnitedHealthcare follows InterQual for primary medical/surgical criteria. Benefit coverage is ultimately governed by federal, state (Ohio Administrative Code), or contractual requirements; in the event of conflict, those requirements govern. Prior to submission, verify member benefits and any plan-specific requirements (including prior authorization rules) because inclusion of a procedure code in this policy does not guarantee coverage or payment.

Background

Hysterectomy is the surgical removal of the uterus and may include removal of the ovaries and fallopian tubes. It is performed for benign conditions such as fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding, and may also be considered for cancer risk reduction in select patients (for example individuals with certain BRCA1/2 pathogenic variants). Procedures can be performed by vaginal, abdominal, laparoscopic, or robotic approaches, with choice of route guided by clinical indications, patient preference, and applicable clinical criteria.

Definitions and Procedure Types

Total laparoscopic hysterectomy (TLH) — definition and brief description

TermTotal laparoscopic hysterectomy (TLH)

DefinitionA laparoscopic procedure in which the uterus is removed using a laparoscope for visualization.

Key featuresUterus may be removed in small pieces through abdominal incisions or extracted through the vagina; additional small abdominal incisions are used for instruments; laparoscope projects images to a monitor to guide surgery.

Supracervical (subtotal) hysterectomy — definition

TermSupracervical (subtotal) hysterectomy

DefinitionSurgical removal of the upper portion of the uterus while leaving the cervix in place.