This policy version was replaced on August 2, 2021. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Hysterectomy, the removal of the uterus, is the most commonly performed gynecological surgical procedure. There are broad diagnostic categories of indications for hysterectomy, including, but not limited to, the treatment of uterine leiomyomas (fibroids), abnormal uterine bleeding, pelvic organ prolapse, pelvic pain or infection (e.g. endometriosis, pelvic inflammatory diseases), and malignant/premalignant disease. Hysterectomy is considered a definitive surgical treatment for those who will no longer maintain fertility.

NOTE:

• This policy applies to commercial health plan members only.
• This policy does not apply to hysterectomy for the presence or suspicion of malignancy.
• This policy does not apply to treatment of gender dysphoria.

I.    Hysterectomy surgery for a non-malignant condition may be considered MEDICALLY NECESSARY AND APPROPRIATE for ANY of the following conditions:

• An emergent condition (e.g., ongoing heavy bleeding with a critically low hemoglobin level or unstable vital signs; postpartum hemorrhaging which cannot be controlled by conservative measures; uterine rupture during labor);
• Abnormal uterine bleeding (i.e., menorrhagia, hypermenorrhea) when ALL of the following criteria are met:
  • No evidence of other pathology treatable by other means; AND
  • Endometrial sampling including ONE of the following:
    • In a pre-menopausal woman, endometrial sampling has been done and is negative for cancer or cannot be done; or
    • For post-menopausal women, either endometrial stripe less than 4mm on uterine imaging or endometrial biopsy negative for cancer; 
  • AND
  • Significant bleeding is recurrent in nature, significantly affecting activities of daily living; AND
  • Failure of BOTH of the following treatments:
    • Hormonal therapy (i.e., progesterones, estrogens, progestin intra-uterine device [IUD]); and
    • Endometrial ablation or documentation that endometrial ablation is contraindicated;
• Adenomyosis in a parous woman, based on clinical examination and ultrasonographic or other radiologic evidence;
• Chronic pelvic inflammatory disease (PID) unresponsive to medical management including ALL of the following:
  • Insufficient clinical response to appropriate intravenous antibiotic therapy; AND
  • If related to tubo-ovarian abscess, percutaneous drainage is not indicated or not feasible;
• Endometriosis when ALL of the following criteria are met:
  • Diagnosis of endometriosis is surgically confirmed; AND
  • Failure, intolerance or contraindication to hormone treatment (i.e., birth control pills) or gonadotropin-releasing hormone (GnRH) agonist therapy (i.e., Lupron); AND
  • Disabling pelvic pain causing persistent impairment in activities of daily living;
• Leiomyomata (fibroid) when ALL of the following criteria are met:
  • Clinically significant symptoms, as indicated by ONE or MORE of the following:
    • Recurrent moderate to severe bleeding related to a diagnosed uterine fibroid;
    • Extra-uterine symptoms, including but not limited to bowel or bladder compression or dyspareunia;
  • AND
  • Documentation of the presence of uterine leiomyomata by appropriate imaging (e.g. ultrasonography); AND
  • Appropriate evaluation of the uterine lining:
    • In a pre-menopausal woman, endometrial sampling has been done and is negative for cancer or cannot be done; or
    • For post-menopausal women, either endometrial stripe less than 4mm on uterine imaging or endometrial biopsy negative for cancer;
• Pelvic pain when ALL of the following criteria are met:
  • No other treatable cause for the pain has been established after clinical evaluation (including laparoscopy) and non-gynecologic sources of pain (e.g., gastrointestinal, musculoskeletal, neurologic, psychological, psychosexual, and/or urinary) have been excluded; AND
  • Pain symptoms interfere significantly with activities of daily living at least one or more days each month; AND
  • Conservative treatment (oral contraceptives, hormone-releasing IUDs, analgesics, non-steroidal medications, gonadotropin-releasing hormone [GnRH] analogs, Depo-Provera, physical therapy) have ALL been unsuccessful or ALL are contraindicated;
• Pelvic relaxation (prolapse) when BOTH of the following criteria are met:
  • Symptomatic uterine prolapse (second-degree or greater; cervix has descended to introitus or further); AND
  • Failure, or contraindication to, or individual non-acceptance of a nonsurgical option, such as the use of a pessary;
• Cervical intraepithelial neoplasia (CIN) when recurrent high-grade lesion (CIN2 or CIN 3) is confirmed by biopsy after patient has had prior excisional or destructive therapy for CIN disease;
• Preventive gynecologic surgical intervention for a patient with ONE OR MORE of the following:
  • Genetic counseling and testing confirming the patient is at high risk of hereditary nonpolyposis colorectal cancer (HNPCC, Lynch Syndrome);
  • Genetic counseling and testing confirming the patient is at high risk due to the presence of one or more known genetic variant(s) associated with ovarian cancer (e.g., BRCA1, BRCA2) when hysterectomy is performed with oophorectomy.

II.   Hysterectomy surgery for a non-malignant condition is considered NOT MEDICALLY NECESSARY when the criteria above are not met.