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Department of Human Services Department of Human Services  

Revised: 11-29-2011

Refer to the Reproductive Health/OB-GYN overview page for links to other related services.

A hysterectomy is a medically necessary procedure or operation for the purpose of removing the uterus. MHCP does not cover hysterectomies for sterilization purposes.

Eligible Providers
Providers must be enrolled with MHCP.

• Ambulatory surgical centers
• CRNA’s
• Hospitals
• Indian health facility provider
• Nurse midwife
• Nurse practitioner
• Physician assistant
• Physicians

Eligible Recipients
All female MHCP recipients.

Authorization and Service Requirements
Prior authorization is required for all hysterectomies unless an exceptional circumstance exists. MHCP requires the provider to secure patient acknowledgment to perform a hysterectomy by informing the individual (and her representative, if applicable), the hysterectomy will make her permanently incapable of reproducing.

Conditions supporting medical necessity for hysterectomy may include but are not limited to the following:

• Malignant disease of the cervix, uterus, ovaries, or fallopian tubes
• Symptomatic uterine fibroids (leiomyomas) that are either
• Causing bladder pressure, pain, fullness, functional disturbance
• Bleeding unresponsive to conservative therapy
• Showing rapid and progressive enlargement
• Recurrent or persistent uterine bleeding or discharge with failure to respond to conservative management
• Confirmed diagnosis of endometriosis with documented failure of non surgical management, e.g. use of hormonal therapy (if not contraindicated) and/or low dose contraceptives
• Endometritis that is unresponsive to conservative management
• Chronic pelvic inflammatory disease unresponsive to conservative management
• Adenomatous endometrial hyperplasia with moderate or severe atypia recurring despite conservative management
• Obstetrical catastrophes, such as uncontrollable postpartum bleeding, uterine rupture, uncontrolled uterine sepsis developing from septic abortion, placenta accretion, etc.
• Septic abortion not responsive to conservative management
• Removal of the uterus in non-gynecologic pelvic surgery where necessary to encompass disease originating elsewhere, as in uterine involvement in colon cancer or in abscess secondary to diverticulitis
• Symptomatic uterine prolapse or descent resulting in general pelvic relaxation

Other conditions determined to be medically necessary.

The Code of Federal Regulations (42 CFR 441.250 – 441.259) outlines requirements, including recipient acknowledgment of information, that must be complied with in order for MHCP to reimburse providers for performing hysterectomy procedures.

A written Hysterectomy Acknowledgment Statement (HAS) is required in order for the procedure to be covered.

Written Acknowledgment
• Do not use the Sterilization Consent Form to obtain written acknowledgement for a hysterectomy. MHCP does not cover a hysterectomy as a means for sterilization
• The recipient and her representative, if any, must sign a Hysterectomy Acknowledgment Statement (HAS) verifying that they received this information, both orally and in written form
• The recipient or guardian may sign the HAS before or after the hysterectomy. However, if the statement is signed after the hysterectomy, it must indicate that before the surgery took place, the recipient was informed the hysterectomy would make her sterile
• Guardians must sign the HAS for mentally incompetent recipients
• A recipient residing in an institution, such as a regional treatment center, may sign the HAS for herself unless she has been found incompetent by a court or unless the head of the institution determines that the recipient is incompetent and requires a representative

The HAS must be faxed as an attachment following the Electronic Claim Attachment instructions on any claim(s) submitted by the physician, anesthesiologist, CRNA, and hospital.

Sample Hysterectomy Acknowledgment Statement
This is a sample HAS. It is not mandatory for the provider to use this sample acknowledgment statement. Any document that the recipient, or her representative, has signed that shows the provider informed the recipient that she would be incapable of reproducing due to the hysterectomy is permissible.

My doctor informed me, both orally and with written materials, that the performance of a hysterectomy would make me sterile (not able to have children).

Signed ___________________________ Date _____________________________

If the recipient signs the acknowledgment after the hysterectomy, the acknowledgment must show that the recipient was informed of the consequences of the hysterectomy before the procedure was performed.

Exceptions to HAS
The written HAS requirement is waived in the following situations:

• Life-threatening Emergency: When a recipient needs a hysterectomy because of a life-threatening emergency in which a physician determines that prior acknowledgment is not possible. The physician must provide a written certification (including physician signature and date) that prior acknowledgment was not possible and describe the nature of the emergency. This certification must accompany all claims for services associated with the hysterectomy.
• Recipient Already Sterile: A hysterectomy performed on a recipient who was sterile before the surgery is not subject to the written acknowledgment requirement.
• In both situations the physician who performed the hysterectomy, must provide a written certification (including physician signature and date) that prior acknowledgment was not possible and describe the nature of the emergency, or of the recipient’s sterility and the cause of the sterility
• The physicians certification must be faxed as an attachment following the Electronic Claim Attachment instructions on all hysterectomy claims

Sample Statement – Recipient Already Sterile
(Patient’s name) had a tubal ligation procedure on (date) making her sterile prior to the hysterectomy performed on (date).

Signature of physician: _____________________________Date: ____________________

Covered Services
All medically necessary hysterectomy procedures/operations for the purpose of removing the uterus.

Non-Covered Services
A hysterectomy is not covered when:

• Performed solely for the purpose of making a recipient sterile; or
• More than one purpose exists for the procedure, and the hysterectomy would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

• Use a 837P or 837I
• Fax a copy of the Hysterectomy Acknowledgement Statement following the Electronic Claim Attachment instructions for all hysterectomy claims, including physician, anesthesiologist, CRNA, hospital, or surgical center

Legal References
42 CFR 441.250 – 441.259 (sterilization and hysterectomy)

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