HYSTERECTOMY (PREAUTHORIZATION REQUIRED)

III.209





III.209 HYSTERECTOMY (PREAUTHORIZATION REQUIRED)


Policy

INTERQUAL CRITERIA



Dates

  • Original Effective
    01-01-2015
  • Last Review
    05-01-2024
  • Next Review
    05-05-2025

Description

Hysterectomy is the most commonly performed gynecological surgical procedure. There are 5 broad diagnostic categories of indications for hysterectomy: leiomyomata, pelvic pain, pelvic organ prolapse, abnormal uterine bleeding, and pelvic cancers (endometrial cancer, cervical cancer, ovarian cancer).

 

Surgical Procedures

Total Abdominal Hysterectomy (TAH) describes the most commonly performed hysterectomy procedure in which the uterine fundus is removed. It may be performed through either a transverse or vertical abdominal incision. This is the preferred procedure where evaluation of the entire pelvis is necessary and conservation of the cervix is not desired.

Vaginal Hysterectomy (VH) is performed entirely through the vagina when the exploration of the upper pelvic area is not required. The most common conditions for this procedure include uterine prolapse.

Radical Hysterectomy (RH) involves the removal of the parametrial tissue and the upper vagina in conjunction with the uterine fundus and cervix, and includes lymph node sampling. The ovaries and fallopian tubes are often removed as well. This procedure is most commonly performed in the treatment of gynecologic cancers. Complications could include bladder and bowel dysfunction, and ureteral injury.

Supracervical Hysterectomy (SH) can be performed abdominally or vaginally, and is the preferred procedure when conservation of the cervix is desired. The fundus of the uterus is removed below the level of the uterine vessels and the cervix is left intact.

Laparoscopic hysterectomy is a general term referring to a spectrum of procedures that differ in the proportion of the hysterectomy that is performed laparoscopically and the proportion performed by vaginal techniques. The technical difficulty of the procedure increases as more components of the operation are performed under laparoscopic guidance. With the exception of laparoscopic radical hysterectomy, laparoscopic approaches are considered alternatives to abdominal hysterectomies, due to the lower morbidity associated with the minimal abdominal incisions and handling of the bowel. However, these advantages may not apply to those patients who would be considered for conventional vaginal hysterectomies.

 



Quick Code Search

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Procedure

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Diagnosis

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Codes

      
          Full Description
            Resection of Bilateral Ovaries, Open Approach
      
          Full Description
            Resection of Bilateral Ovaries, Percutaneous Endoscopic Approach
      
          Full Description
            Resection of Bilateral Fallopian Tubes, Open Approach
      
          Full Description
            Resection of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
      
          Full Description
            Resection of Uterus, Percutaneous Endoscopic Approach
      
          Full Description
            Resection of Uterus, Via Natural or Artificial Opening
      
          Full Description
            Resection of Uterus, Via Natural or Artificial Opening Endoscopic
      
          Full Description
            Resection of Cervix, Percutaneous Endoscopic Approach
      
          Full Description
            Resection of Cervix, Via Natural or Artificial Opening
      
          Full Description
            Supplement Cul-de-sac with Autologous Tissue Substitute, Open Approach
      
          Full Description
            Supplement Cul-de-sac with Synthetic Substitute, Open Approach
      
          Full Description
            Supplement Cul-de-sac with Nonautologous Tissue Substitute, Open Approach
      
          Full Description
            Supplement Cul-de-sac with Autologous Tissue Substitute, Percutaneous Endoscopic Approach
      
          Full Description
            Supplement Cul-de-sac with Synthetic Substitute, Percutaneous Endoscopic Approach
      
          Full Description
            Supplement Cul-de-sac with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach
      
          Full Description
            Supplement Cul-de-sac with Autologous Tissue Substitute, Via Natural or Artificial Opening
      
          Full Description
            Supplement Cul-de-sac with Synthetic Substitute, Via Natural or Artificial Opening
      
          Full Description
            Supplement Cul-de-sac with Nonautologous Tissue Substitute, Via Natural or Artificial Opening
      
          Full Description
            Supplement Cul-de-sac with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic
      
          Full Description
            Supplement Cul-de-sac with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic
      
          Full Description
            Supplement Cul-de-sac with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic
      
          Full Description
            Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
      
          Full Description
            Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
      
          Full Description
            Vaginal hysterectomy, for uterus 250 g or less
      
          Full Description
            Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
      
          Full Description
            Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
      
          Full Description
            Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
      
          Full Description
            Vaginal hysterectomy, for uterus greater than 250 g
      
          Full Description
            Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
      
          Full Description
            Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
      
          Full Description
            Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele
      
          Full Description
            Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
      
          Full Description
            Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
      
          Full Description
            Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
      
          Full Description
            Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
      
          Full Description
            Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
      
          Full Description
            Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
      
          Full Description
            Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
      
          Full Description
            Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
      
          Full Description
            Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
      
          Full Description
            Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
      
          Full Description
            Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
      
          Full Description
            Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
      
          Full Description
            LAPAROSCOPY, SURGICAL, TOTAL HYSTERECTOMY FOR RESECTION OF MALIGNANCY (TUMOR DEBULKING), WITH OMENTECTOMY INCLUDING SALPINGO-OOPHORECTOMY, UNILATERAL OR BILATERAL, WHEN PERFORMED