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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

1E-1, Hysterectomy

Service Code
58285 (CPT) Vaginal hysterectomy, radical (Schauta type operation)
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

1E-1, Hysterectomy

Service Code
58290 (CPT) Vaginal hysterectomy, for uterus greater than 250 g;
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

1E-1, Hysterectomy

Service Code
58291 (CPT) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
Prior Authorization Required
Yes
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

Prior authorization may be required. Check North Carolina clinical coverage policy 1S-10, Genetic Testing for Carrier and Prenatal for more information

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

Resources

1E-1, Hysterectomy

Service Code
58292 (CPT) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

1E-1, Hysterectomy

Service Code
58293 (CPT) Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

1E-1, Hysterectomy

Service Code
58294 (CPT) Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Hysterectomy is defined as the operation of excising the uterus either through the abdominal wall or through the vagina.

Limits

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy. Covered only when performed at the time of an abdominal hysterectomy.

Length of Stay

Covered once in a lifetime per individual

Exclusions

Dilation and curettage is not covered when performed in conjunction with a vaginal hysterectomy.

Diagnosis Requirements

Accepted diagnoses validating medical necessity are malignant and pre-malignant lesions of the female reproductive tract; endometriosis; adenomyosis; leiomyomas or fibroids; salpingitis and oophoritis; mild to moderate cervical dysplasia when prior conservative procedures failed; hyperplasia of the endometrium; dysfunctional uterine bleeding, severe idiopathic menorrhagia and/or metrorrhagia; inflammatory peritonitis; intractable procidentia (prolapsed uterus); perforation of the uterus by IUD; Class IV or V pap smear; prophylactic oophorectomy for positive family history of BRCA-1; traumatic injury to the uterus with irreparable damage; and complications of childbirth such as uterine rupture or intractable hemorrhage for Medicaid beneficiaries only. Health record documentation must support medical necessity and must be submitted for individuals under age 21 and for pelvic inflammatory disease, mild to moderate cervical dysplasia when prior conservative procedures failed, carcinoma in situ of unspecified organs, and uterine hemorrhage from placenta previa.

Place of Service

Inpatient hospital, Outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Insertion of intrauterine device (IUD)

Service Code
58300 (CPT) Insertion of intrauterine device (IUD)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal of intrauterine device (IUD)

Service Code
58301 (CPT) Removal of intrauterine device (IUD)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Artificial insemination; intra-cervical

Service Code
58321 (CPT) Artificial insemination; intra-cervical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Artificial insemination; intra-uterine

Service Code
58322 (CPT) Artificial insemination; intra-uterine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Sperm washing for artificial insemination

Service Code
58323 (CPT) Sperm washing for artificial insemination
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography

Service Code
58340 (CPT) Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography

Service Code
58345 (CPT) Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Insertion of Heyman capsules for clinical brachytherapy

Service Code
58346 (CPT) Insertion of Heyman capsules for clinical brachytherapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Chromotubation of oviduct, including materials

Service Code
58350 (CPT) Chromotubation of oviduct, including materials
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Endometrial ablation, thermal, without hysteroscopic guidance

Service Code
58353 (CPT) Endometrial ablation, thermal, without hysteroscopic guidance
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed

Service Code
58356 (CPT) Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure)

Service Code
58400 (CPT) Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; with presacral sympathectomy

Service Code
58410 (CPT) Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; with presacral sympathectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hysterorrhaphy, repair of ruptured uterus (nonobstetrical)

Service Code
58520 (CPT) Hysterorrhaphy, repair of ruptured uterus (nonobstetrical)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required