58267
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
17.90
Facility
$939.90
Non-Facility
$939.90
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled 'Medical Records Documentation Used for Reviews.'
- Documentation supporting the specific clinical indication (for example pathology, imaging, diagnoses such as BRCA1/BRCA2 positive genetic testing, history of tamoxifen use, documentation of prior/conservative treatments tried and failed, and counseling regarding fertility desires) to demonstrate meeting InterQual® criteria or other medical necessity requirements.
- Member specific benefit plan document should be referenced and documentation should support applicability of plan benefits and any applicable federal/state mandates.
- Informed consent and counseling documentation when discussing risks and benefits of prophylactic hysterectomy at time of RRSO (including counseling about tamoxifen-associated uterine risk) and documentation of patient decision-making.
Key Coverage Criteria
- Benign conditions that might be treated with a hysterectomy include endometriosis.
- Benign conditions that might be treated with a hysterectomy include uterine fibroids.
- Hysterectomy is proven and medically necessary for management of individuals with BRCA1 or BRCA2 gene mutation.
- Hysterectomy is proven and medically necessary in certain circumstances as defined by the InterQual® CP: Procedures, Hysterectomy, +/- Bilateral Salpingo-Oophorectomy (BSO) or Bilateral Salpingectomy (i.e., coverage per InterQual® clinical criteria).
- Benign conditions that might be treated with a hysterectomy include pelvic organ prolapse.
- Benign conditions that might be treated with a hysterectomy include abnormal uterine bleeding.
4 Active Policies
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
UHC-POL-hysterectomy — Hysterectomy
UMR-POL-UMR-hysterectomy — Hysterectomy
SUREST-POL-SUREST-hysterectomy — Hysterectomy
Related Codes
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