Point32 Hysterectomy, Certain Elective(Eff. beginning 1.1.24) Form

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations.

Article - Sterilization (A59060) (cms.gov) is being supplemented using InterQual to provide additional detail regarding medical necessity criteria. For the service of Hysterectomy, evidence is sufficient for coverage. In addition to the coverage of hysterectomy for illness or injury referenced in this CMS Article, InterQual provides guidance for the use of hysterectomy for various indications. The guidance for the use of this expanded criteria for these indications is supported American Congress of Obstetricians and Gynecologists. The use of this criteria in the utilization management process will ensure access to evidence based clinically appropriate care. See References section below for all evidence accessed in the development of these criteria.

Clinical Guideline Coverage Criteria

The Plan requires the use of the following InterQual Subsets or SmartSheets to obtain prior authorization for hysterectomy:

• Hysterectomy, +/- BSO for Abnormal Uterine Bleeding or Postmenopausal Bleeding
• Hysterectomy, +/- BSO for Adenomyosis or Fibroids
• Hysterectomy, +/- BSO for BRCA gene mutation
• Hysterectomy, +/- BSO for Chronic Abdominal or Pelvic Pain
• Hysterectomy, +/- BSO for CIN 2, CIN 2,3 or CIN 3 or Endometrial Hyperplasia (premenopausal)
• Hysterectomy, +/- BSO for Endometrial hyperplasia (postmenopausal)
• Hysterectomy, +/- BSO for Endometriosis
• Hysterectomy, +/- BSO for Lynch II syndrome
• Hysterectomy, +/- BSO for Pelvic Inflammatory Disease (PID) or Tubo-ovarian abscess
• Hysterectomy, +/- BSO for for Postpartum uterine bleeding
• Hysterectomy, +/- BSO for Uterine Prolapse

Codes