ModifiedUnitedHealthcarePolicy CS196TN.I

Hysterectomy (for Tennessee Only)

Medical policy governing coverage and medical necessity criteria for hysterectomy for Tennessee Medicaid and CoverKids members, including consideration of prophylactic hysterectomy for BRCA1/2 mutation carriers and references to InterQual criteria.

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Tennessee Only)

Policy CodePolicy CS196TN.I

Change TypeMaterial updates to documentation requirementsclarifications and reference updates

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure medical records fully document history, exam, and relevant test results and make them available upon request to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and listing examples of required documentation.

Clarified that benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service.

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

InterQualPrimary clinical criteria source

BRCA1/2BRCA indication noted

TennesseeState-specific

Comprehensive

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.

Morcellator warningFDA contraindication

RequiredDocumentation requirement

Coverage and Medical Necessity Criteria

Medical necessity and referenced criteria

Covered when supported by InterQual clinical criteria or specific indication:

Primary covered indications: Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation and in certain other circumstances when medical necessity criteria are met per InterQual CP: Procedures, Hysterectomy +/- BSO or Bilateral Salpingectomy.

InterQual criteria must be consulted for specific clinical indications and details.

NCCN guidance on concurrent hysterectomy at RRSO

Prophylactic considerations for BRCA carriers:

BRCA1/2 and RRSO considerations: For individuals with BRCA1 or BRCA2 pathogenic or likely pathogenic variants, clinicians should discuss the risks and benefits of concurrent hysterectomy at the time of risk-reducing salpingo-oophorectomy (RRSO). Timing of RRSO is generally between 35 and 40 years for BRCA1 carriers and between 40 and 45 years for BRCA2 carriers, unless family history warrants earlier intervention.

NCCN recommends discussion but does not mandate prophylactic hysterectomy.

Listing of a procedure or diagnosis code in this policy is provided for reference only and does not imply the service is covered. Benefit coverage for health services is determined by applicable federal, state, or contractual requirements and laws that may mandate coverage for a specific service. The inclusion of a code does not guarantee reimbursement or claim payment, and other policies or guidelines may apply when making coverage or payment determinations.

The policy includes informational material from the U.S. Food and Drug Administration regarding laparoscopic power morcellators. The FDA labeling contains a prominent warning that uterine tissue may contain unsuspected cancer and that use of power morcellators during fibroid surgery may spread cancer and adversely affect long‑term survival; this risk should be discussed with patients when considering morcellation. The FDA also lists specific contraindications: power 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 (for example via the vagina or mini‑laparotomy) is an option.

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization requirements apply per this policy and the member's contract. Verify prior authorization and benefit coverage rules with UnitedHealthcare before scheduling procedures.

Check member-specific benefits and eligibility.
Prior authorization may be required per contract and federal/state rules.

Note

Prior Authorization and Benefit Determination

Coverage decisions reference federal, state, or contractual requirements. UnitedHealthcare may request medical records to determine whether the member meets clinical criteria; provision of records does not guarantee coverage.

Benefit coverage is governed by applicable federal, state, or contractual requirements.
Medical records may be requested to assess clinical criteria for coverage.

Procedure 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.

1–10 of 11

1/2

Laparoscopic-assisted vaginal and Vaginal CPT codesCPT

58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less.
58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g.
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
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.

1–10 of 13

1/2

Clinical Background

A hysterectomy is a surgical procedure to remove the uterus; it may also include removal of the fallopian tubes and/or ovaries. Hysterectomy is commonly performed to treat benign conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding, and can be performed by several approaches including vaginal, abdominal, laparoscopic (including total laparoscopic and laparoscopic‑assisted vaginal), or robotic‑assisted techniques.

Definitions and Terms

inv-16: Total hysterectomy — Removal of the entire uterus including the cervix

DefinitionRemoval of the entire uterus including the cervix.

Common indications (from background)Benign conditions such as uterine fibroids, endometriosis, pelvic organ prolapse, and abnormal uterine bleeding may be treated with total hysterectomy.

Surgical approachesCan be performed vaginally, abdominally, laparoscopically (including total laparoscopic), or with robotic assistance.

inv-17: Supracervical (partial) hysterectomy — Removal of upper part of uterus with cervix left in place

DefinitionRemoval of the upper part of the uterus with the cervix left in place.

CPT examplesSupracervical/subtotal hysterectomy CPT codes include abdominal and laparoscopic supracervical codes (see policy coding sections).

Policy Summary

PayerUnitedHealthcare

PolicyHysterectomy (for Tennessee Only)

Policy CodePolicy CS196TN.I

Change TypeMaterial updates to documentation requirementsclarifications and reference updates

Effective DateFeb 1, 2026

Next Review Date

Key ActionEnsure medical records fully document history, exam, and relevant test results and make them available upon request to support medical necessity.

SourceLink

On This Page

Note

Consider Non-surgical Therapy Before Hysterectomy

Consider non-surgical therapy prior to hysterectomy for conditions such as adenomyosis or chronic pelvic pain when clinically appropriate. Options with evidence of benefit include levonorgestrel-releasing intrauterine system (LNG-IUS) and oral dienogest.

Consider LNG-IUS (levonorgestrel intrauterine system) as an alternative to hysterectomy where appropriate.
Consider dienogest for control of bleeding and pelvic pain prior to surgical intervention.

Documentation Required

Documentation and Provider Actions

Benefit coverage determinations may require review of the member’s medical record and adherence to policy documentation standards. Providers should be prepared to supply requested records to support medical necessity.

Medical history, physical examination findings, and results of pertinent diagnostic tests should be documented.
Failure to provide requested documentation may delay or result in denial of authorization.

Documentation Required

Required Medical Documentation

The patient’s medical record must contain documentation that fully supports medical necessity for requested services. Documentation should be legible, maintained in the medical record, and available upon request.

Include relevant medical history, physical exam, and results of diagnostic tests or procedures.
Documentation that does not adequately support medical necessity may result in denial or non-coverage.

Denial Risk

Documentation-Related Denial Risk

Failure to provide complete and adequate documentation to support medical necessity may result in denial of coverage or non-payment.

Ensure records fully justify the clinical need for the requested service.
Maintain legible records and supply them promptly when requested.

Clinical contextMay be considered when cervix preservation is desired and not contraindicated by pathology.

inv-18: Approaches — Vaginal, abdominal, laparoscopic, robotic-assisted approaches described

Approaches listedVaginal, abdominal, laparoscopic (including total laparoscopic and laparoscopic-assisted vaginal), and robotic-assisted techniques.

Vaginal approachUterus removed through the vagina (vaginal hysterectomy). Useful for prolapse and some benign conditions.

Abdominal approachUterus removed through an incision in the lower abdomen (abdominal hysterectomy).

Laparoscopic approachesLaparoscope used to guide surgery; includes total laparoscopic hysterectomy (uterus removed in small pieces) and laparoscopic-assisted vaginal hysterectomy; robotic assistance is an option.

inv-19: Chronic pelvic pain — Pelvic pain lasting >= 6 months (per NICE guidance)

DefinitionPelvic pain lasting for 6 months or longer (per NICE guidance).

AssociationIdentified by NICE as a sign/symptom of endometriosis; considered in guidelines for chronic pelvic pain management.

Surgical considerationHysterectomy may be an option for endometriosis or adenomyosis when severe symptoms persist and other treatments have failed, particularly if fertility is no longer desired.

inv-20: Risk-reducing salpingo-oophorectomy (RRSO) — Prophylactic removal of tubes/ovaries for BRCA1/2 carriers; NCCN recommendations

DefinitionProphylactic removal of the fallopian tubes and ovaries, often performed for individuals with BRCA1/2 pathogenic or likely pathogenic variants.

NCCN timing recommendationNCCN recommends RRSO typically between ages 35–40 for BRCA1 and 40–45 for BRCA2 carriers, unless family history suggests earlier intervention.

Concurrent hysterectomy guidanceNCCN states patients should discuss risks and benefits of concurrent hysterectomy at time of RRSO; discussion is recommended but hysterectomy is not universally mandated.

SOGC viewSOGC advises individualizing inclusion of hysterectomy with RRSO, considering uterine cancer risk factors, other uterine pathology, and tamoxifen use; routine hysterectomy for uterine cancer risk reduction in BRCA1 carriers is not routinely recommended due to insufficient data.