Does 58294 require prior authorization?

No, 58294 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 58294?

Medicare facility rate: $1069.50. Non-facility rate: $1069.50. Work RVU: 21.01.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

21.01

Facility

$1069.50

Non-Facility

$1069.50

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.

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.

AMBETTER-CP.MP.95 — Gender-Affirming Procedures

AETNA-CPB-0512 — Premenstrual Syndrome and Premenstrual Dysphoric Disorder

UHC-POL-hysterectomy — Hysterectomy

UMR-POL-UMR-hysterectomy — Hysterectomy

SUREST-POL-SUREST-hysterectomy — Hysterectomy

Ask Verity about documentation requirements, denial risks, or coverage in your state.