ModifiedUnitedHealthcarePolicy 2026T0572Y

Hysterectomy (including approaches and indications) - Clinical Medical Policy

UnitedHealthcare medical policy describing coverage rationale, clinical context, and coding references for hysterectomy (abdominal, vaginal, laparoscopic/robotic) for commercial and individual exchange plans; includes discussion of indications such as BRCA1/2 mutation and other benign gynecologic conditions and references to InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (including approaches and indications) - Clinical Medical Policy

Policy CodePolicy 2026T0572Y

Change TypeDocumentation and reference updates

Effective DateJan 1, 2026

Next Review Date

Key ActionProvide complete medical records including personal and family history, recent imaging and diagnostic reports, prior treatments with dates and reasons for discontinuation, physical exam, and the physician treatment plan when submitting for prior authorization or medical review.

SourceLink

POLICY UPDATE CHANGES

Updated list of medical records documentation used for reviews, with additions, removals, and rewording of several required documentation items.

Supporting clinical evidence and references sections were updated to reflect the most current information.

BRCA1/2mutation cited as indication for hysterectomy consideration

InterQualexternal criteria referenced for medical necessity

CPT listmultiple CPT hysterectomy procedure codes listed

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FDA morcellator boxed warningdevice safety notice referenced

1/01/2026policy history update date

Coverage Criteria

General Coverage Rationale

Covered when supported by clinical necessity per referenced criteria:

Primary coverage logic: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation and is medically necessary in certain other circumstances per InterQual CP: Procedures, Hysterectomy +/- Bilateral Salpingo-Oophorectomy (BSO) or bilateral salpingectomy.

Providers must refer to InterQual criteria for specific clinical indications and required documentation.

BRCA1/2 and prophylactic hysterectomy considerations

Clinical considerations and nuance regarding BRCA1/2 mutation carriers:

BRCA-related considerations: Literature and guideline sources report an increased (approximately 2–3 fold) risk of endometrial cancer in BRCA1/2 carriers in some studies; prophylactic hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO) remains controversial and should be discussed with the patient, considering tamoxifen exposure and individual risk factors.

NCCN recommends discussing risks/benefits of concurrent hysterectomy at time of RRSO for BRCA1/2 P/LP variant carriers; systematic reviews and meta-analyses present mixed evidence and recommend individualized decision-making.

Guideline summaries

Guideline summaries relevant to hysterectomy and related risk-reducing procedures

ACOG guidance: ACOG Practice Bulletin #793 addresses hereditary cancer risk assessment and is silent on prophylactic hysterectomy; ACOG Committee Opinion #601 recommends counseling women on tamoxifen about endometrial risks and considering hysterectomy for atypical endometrial hyperplasia if tamoxifen is to be continued.

clinical counseling and management recommendations

NCCN guidance: NCCN recommends discussion of risks and benefits of concurrent hysterectomy at the time of RRSO for individuals with BRCA1/2 pathogenic/likely pathogenic variants and provides timing guidance for RRSO (typically age 35–40 for BRCA1 and 40–45 for BRCA2, individualized by family history).

recommendation to individualize timing and discuss concurrent hysterectomy

NICE guidance: NICE supports laparoscopic hysterectomy as safe and effective for endometrial cancer but is silent on prophylactic hysterectomy for BRCA mutation; NICE defines chronic pelvic pain as pelvic pain lasting 6 months or longer for endometriosis evaluation.6 months

Coverage is determined by the member-specific benefit plan and applicable medical necessity criteria. In this policy, coverage for hysterectomy procedures is provided when supported by clinical necessity per referenced external criteria: specifically, refer to the InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy for the detailed medical necessity elements and documentation requirements.

The policy notes device-specific safety guidance: laparoscopic power 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 is an option. This FDA‑identified risk should be considered and discussed with the patient during surgical planning.

This inventory item did not include a summary in the brief or source document. No additional coverage language is provided here.

Coding (CPT/HCPCS/ICD-10)

Covered CPT Codes (abdominal and laparoscopic partial list)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 (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.

Covered CPT Codes (vaginal and laparoscopic-assisted vaginal)CPT

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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Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Coverage for hysterectomy (with or without bilateral salpingo‑oophorectomy or bilateral salpingectomy) is subject to prior authorization and must meet the InterQual® CP: Procedures, Hysterectomy, +/- BSO or bilateral salpingectomy clinical criteria.

InterQual® criteria referenced for prior authorization — see InterQual CP: Procedures, Hysterectomy, +/- BSO or bilateral salpingectomy.
Prior authorization determinations are member‑specific and require verification of benefits and eligibility.

Documentation Required

Documentation Required for Review

Documentation Required for Review: UnitedHealthcare may require medical records and supporting documentation to determine whether the requested service meets clinical criteria and the member’s benefit plan. Required documentation should be current, complete, and directly support the clinical indication for the procedure.

Requested documentation may include relevant personal and family history, relevant physical exam, physician treatment plan, all recent reports of relevant imaging studies and diagnostic tests, pathology and laboratory results (including genetic testing if applicable), and recent surgical and diagnostic procedure history (e.g., endometrial sampling, PAP, hysteroscopy, D&C).

Background

A hysterectomy is a surgical procedure to remove the uterus and may include concurrent removal of the fallopian tubes and/or ovaries. It is performed for a range of benign gynecologic conditions such as fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding, and may be performed via abdominal, vaginal, laparoscopic (including robotic-assisted) approaches. The policy highlights that hysterectomy is considered medically necessary for management of individuals with a BRCA1 or BRCA2 gene mutation and that other indications are adjudicated using InterQual clinical criteria.

Definitions

inv-18: Total hysterectomy — Removal of the entire uterus, including the cervix.

DefinitionRemoval of the entire uterus, including the cervix.

Common indicationsBenign conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding may be treated with total hysterectomy.

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

Most actionableTotal hysterectomy (entire uterus + cervix) is the definitive removal procedure when clinically indicated — confirm documentation of indication per InterQual and member benefit before authorization.

inv-19: Supracervical (partial) hysterectomy — Removal of the upper part of the uterus while leaving the cervix in place.

Definition

Revision History

2026-01-01Material revisionLatest

Template update creating a shared policy version for Oxford plan membership and a material update to the Medical Records Documentation Used for Reviews, adding 'relevant physical exam' and 'physician treatment plan', removing examples of diagnostic report lists, and rewording several documentation items.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (including approaches and indications) - Clinical Medical Policy

Policy CodePolicy 2026T0572Y

Change TypeDocumentation and reference updates

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

diagnostic threshold for chronic pelvic pain

SOGC guidance: SOGC advises individualizing the inclusion of hysterectomy with RRSO for BRCA variant carriers considering uterine cancer risk factors and tamoxifen use and notes insufficient data to routinely recommend hysterectomy to reduce papillary serous uterine cancer risk in BRCA1 carriers.

emphasis on individualization

FDA device safety: FDA boxed warning: laparoscopic power morcellators may spread unsuspected uterine cancer and are contraindicated when tissue is known or suspected to contain malignancy or in peri/postmenopausal patients; this risk should be discussed with patients during surgical planning.

device-specific contraindications and patient counseling

Also include treatments tried, failed, or contraindicated with dates, duration, and reason for discontinuation, and any operative reports if applicable.

Lack of required documentation may result in denial of the prior authorization request.

Documentation Required

Prior Authorization and Documentation

Prior Authorization Process and Member‑Specific Coverage: Prior authorization decisions are made after review of the member’s specific benefit plan and applicable laws or mandates. In the event of a conflict between this policy and the member specific benefit plan, the member specific benefit plan governs. This policy may be used alongside InterQual® criteria and other third‑party tools to administer benefits.

Verify member benefits and eligibility prior to submission.
Provide complete medical records and supporting documentation at time of prior authorization request to avoid delays.
Incomplete or missing documentation (for example: absent genetic test results, missing imaging reports, incomplete treatment history, or absent operative reports) may lead to denial or request for additional information.

Step Therapy

Step Therapy: No step therapy requirements are specified for hysterectomy in this policy. If step therapy requirements exist under the member specific benefit plan, those requirements apply and must be met prior to coverage.

This section does not impose any step therapy sequence for surgical management.
If the member specific benefit plan imposes step therapy or conservative therapy prerequisites, those plan rules control and should be followed.

Removal of the upper part of the uterus while leaving the cervix in place.

SynonymSupracervical hysterectomy (also called partial or subtotal hysterectomy).

Clinical notePreserves the cervix; discuss risks/benefits and document indication and patient counseling in the record for prior authorization review.

ApproachesCan be performed abdominally, vaginally, or laparoscopically depending on clinical circumstances.

inv-20: Vaginal hysterectomy (VH) — Uterus removed through the vagina.

DefinitionUterus removed through the vagina.

IndicationsAppropriate for selected benign conditions; may be combined with laparoscopic assistance when indicated.

Procedure variantsIncludes vaginal hysterectomy and laparoscopic-assisted vaginal hysterectomy where laparoscopy guides the procedure.

Most actionableDocument uterine size and prior surgical history when requesting authorization for vaginal hysterectomy to support medical necessity review.

inv-21: Abdominal hysterectomy (AH) — Uterus removed through an incision in the lower abdomen.

DefinitionUterus removed through an incision in the lower abdomen.

IndicationsOften used for larger uteri or when abdominal access is clinically indicated for concurrent procedures.

Approach noteMay be performed as total or supracervical abdominal hysterectomy depending on clinical need.

Most actionableWhen requesting prior authorization for abdominal hysterectomy, include imaging and documentation supporting need for abdominal approach.

inv-22: Laparoscopic hysterectomy — Use of a laparoscope and small abdominal incisions; may be total, supracervical, or laparoscopic-assisted.

DefinitionUse of a laparoscope and small abdominal incisions to guide removal of the uterus; may be total, supracervical, or laparoscopic-assisted vaginal.

Technique detailsA thin, lighted tube with a camera is inserted through a small incision; additional small incisions allow instruments and tissue removal may be via small incisions or vagina.

VariantsIncludes total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy, and robotic-assisted laparoscopic hysterectomy.

Most actionableSpecify laparoscopic variant and uterine size (e.g., ≤250 g vs >250 g) in documentation and authorization requests to match appropriate CPT coding and InterQual criteria.

inv-23: risk-reducing salpingo-oophorectomy (RRSO) — Definition related to prophylactic removal of fallopian tubes and ovaries.

DefinitionRisk-reducing salpingo-oophorectomy (RRSO) — prophylactic removal of fallopian tubes and ovaries to reduce ovarian cancer risk in high-risk individuals (e.g., BRCA1/2 carriers).

Clinical contextNCCN recommends RRSO for carriers of BRCA1/2 P/LP variants, with timing typically between ages 35–40 for BRCA1 and 40–45 for BRCA2, and discussion of concurrent hysterectomy.

Counseling pointDiscuss risks and benefits of concurrent hysterectomy at time of RRSO for BRCA1/2 pathogenic/likely pathogenic variant carriers.

inv-24: Laparoscopic power morcellator — Class II surgical device labeling includes boxed warning and contraindications when malignancy is known or suspected or in peri/postmenopausal patients

Device classLaparoscopic power morcellator — Class II medical device used during laparoscopic surgery to morcellate uterine tissue.

FDA boxed warningProduct labeling includes a black box warning that uterine tissue may contain unsuspected cancer and morcellation can spread cancer and decrease long-term survival; this should be shared with patients.

ContraindicationsContraindicated when tissue to be morcellated is known or suspected to contain malignancy, and contraindicated for removal of uterine tissue containing suspected fibroids in peri- or post-menopausal patients or when en bloc removal is an option.

Information sourcesRefer to FDA resources for additional product labeling and guidance (FDA morcellator webpages and downloadable guidance documents).