Does 58563 require prior authorization?

No, 58563 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 58563?

Medicare facility rate: $217.11. Non-facility rate: $2009.06. Work RVU: 4.36.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

4.36

Facility

$217.11

Non-Facility

$2009.06

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to Medical Records Documentation Used for Reviews).
For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Hysteroscopy, Operative (for endometrial ablation) and InterQual® CP: Procedures, Uterine Artery Embolization (UAE).
Recommendations prior to UFE treatment include an endometrial biopsy to rule out malignancy or hyperplasia.
Preoperative evaluation should include risk stratification and use of imaging, cervical cancer screening, and endometrial tissue sampling to identify malignancy (per ACOG guidance).

Endometrial ablation is proven and medically necessary for treating abnormal uterine bleeding in premenopausal individuals.
Levonorgestrel-releasing intrauterine devices (LNG-IUD) (e.g., Mirena®, Skyla®, Liletta™, Kyleena™) are proven and medically necessary for treating menorrhagia.
Uterine artery embolization (UAE) is proven and medically necessary for treating symptomatic uterine fibroids, postpartum or post hysterectomy bleeding, or uterine arteriovenous malformation (AVM).
Uterine fibroid embolization (UFE) is indicated for individuals with clinically documented fibroids and fibroid-related symptoms and is a viable alternative to hysterectomy surgery.
Certain intrauterine devices are included in the preventive care services benefit (where applicable by plan document).
LNG-IUD is covered when used for a non-contraceptive purpose, including treatment of abnormal uterine bleeding (in plans that exclude contraceptive use).

AMBETTER-CP.MP.106 — Endometrial Ablation

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

UMR-POL-UMR-abnormal-uterine-bleeding-uterine-fibroids — Abnormal Uterine Bleeding and Uterine Fibroids

SUREST-POL-SUREST-abnormal-uterine-bleeding-uterine-fibroids — Abnormal Uterine Bleeding and Uterine Fibroids

CIGNA-0013

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