Policy/Procedure Number: MCUP3135 / Lead Department: Health Services
Policy/Procedure Title: Hysterectomy Review Policy / ☒External Policy
☐ Internal Policy
Original Date: 04/20/2016 / Next Review Date: 06/13/2019
Last Review Date: 06/13/2018
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MCUP3135 / Lead Department: Health Services
Policy/Procedure Title:Hysterectomy Review Policy / ☒External Policy
☐Internal Policy
Original Date: 04/20/2016 / Next Review Date:06/13/2019
Last Review Date:06/13/2018
Applies to: / ☒Medi-Cal / ☐ Employees
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒ QUAC
☐OPerations / ☐Executive / ☐Compliance / ☐Department
Approving Entities: / ☐BOARD / ☐COMPLIANCE / ☐FINANCE / ☒ PAC
☐ CEO / ☐COO / ☐Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA / Approval Date:06/13/2018
  1. RELATED POLICIES:
  2. MCUP3041 - TAR Review Process
  3. MCUP3119 - Sterilization Consent Protocol
  1. IMPACTED DEPTS:
  2. Health Services
  3. Claims
  4. Member Services
  1. DEFINITIONS:N/A
  1. ATTACHMENTS:
  2. N/A
  1. PURPOSE:
  1. POLICY / PROCEDURE:
  1. Malignant Indications:
  2. Cancer of the cervix, ovaries, fallopian tubes or endometrium
  3. Clinical features highly suspicious of malignancy
  4. Prophylactic gynecologic cancer for hereditary non-polyposis colorectal cancer (Lynch syndrome) or positive BRCA mutation or other genetic propensity to gynecological cancer, according to National Comprehensive Cancer Network (NCCN) guidelines
  5. Malignant gestational trophoblastic disease (choriocarcinoma)
  6. Non-malignant Indications:
  7. Endometrial hyperplasia proven by biopsy in a post-menopausal woman
  8. Endometriosis confirmed by laparoscopy with:
  9. Failure of conservative surgery AND
  10. Failure of >8 weeks of GnRH agonist, or depot medroxyprogesterone or danazol
  1. Abnormal uterine bleeding, premenopausal:
  2. Symptoms for at least 6 months that interfere with activities of daily living AND
  3. Failure of progestin or oral contraceptives for 3 cycles or with a levonorgestrel IUD or after endometrial ablation
  4. Abnormal uterine bleeding, postmenopausal:
  5. Endometrium normal by biopsy or ultrasound AND
  6. Bleeding despite change or discontinuation of hormone replacement therapy
  7. Leiomyomata: fibroids documented on ultrasound AND one of the following:
  8. Bleeding that interferes with activities of daily living, OR
  9. Uterus doubled in size by ultrasound within one year, OR dyspareunia, OR bladder or ureteral compression on ultrasound
  10. Adenomyosis:
  11. Bleeding that interferes with activities of daily living or dyspareunia or pelvic pain AND
  12. Failure of NSAIDs, GnRH or depot medroxyprogesterone or oral contraceptives for 8 weeks
  13. Chronic pelvic pain – ALL of the following:
  14. Diagnostic laparoscopy negative
  15. Diagnostic studies negative for non-gynecologic etiologies
  16. Persistence for longer than 6 months
  17. Interferes with activities of daily living
  18. Pelvic inflammatory disease – Diagnosis confirmed by laparoscopy and ONE of the following:
  19. Chronicpain, greater than two episodes of pelvic inflammatory disease
  20. Tubo-ovarian abscess
  21. Uterine prolapse – ONE of the following:
  22. Second, third, or fourth degree prolapse
  23. First degree prolapse with pelvic pressure, pain or stress incontinence not responding to other therapy (requires review)
  1. REFERENCES:
  2. Current InterQual criteria
  3. National Comprehensive Cancer Network (NCCN) guidelines
  1. DISTRIBUTION:
  2. PHC Department Directors
  3. PHC Provider Manual
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:Senior Director, Health Services
  1. REVISION DATES:

04/19/17; *06/13/18

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO:

N/A

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Inaccordance with theCalifornia Healthand SafetyCode,Section 1363.5,this policywasdevelopedwith involvement from activelypracticinghealth care providersandmeetstheseprovisions:

  • Consistentwith sound clinicalprinciplesand processes
  • Evaluatedand updated atleast annually
  • Ifusedas thebasis ofadecision to modify, delayordenyservices ina specific case, thecriteria will be disclosedto the provider and/orenrollee upon request

The materials provided areguidelinesusedbyPHC to authorize, modifyor denyservices forpersonswithsimilar illnesses or conditions.Specific care andtreatment mayvarydependingonindividualneedand the benefitscovered underPHC.

PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.

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