A hysterectomy is a limited benefit and only covered when medically necessary.
Hysterectomies may be a covered benefit for the following:
- The treatment of pathology (cancer, adenomyosis, fibroids, endometriosis, dysfunctional uterine bleeding)
- The beneficiary is about to undergo or is undergoing tamoxifen therapy
- The beneficiary has been diagnosed with hereditary non-polyposis colorectal cancer (HNPCC) or found to be a carrier of HNPCC-associated mutations
A hysterectomy is not a covered benefit when performed solely for purposes of sterilization and/or hygiene in the absence of pathology.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.