CPT 58263, in plain terms, covers Vaginal hysterectomy for uterus up to 250 g with removal of tubes and or ovaries plus repair of an enterocele. CPT 58263 is referenced in 14 tracked payer policy changes from New Jersey Medicaid, Regence BlueShield, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 58263 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 58263 on AAPC
New Jersey Medicaid and NJ KidCare-Plan A now require second surgical opinions for specific elective procedures including hysterectomy, spinal fusion, laminectomy, and hernia repair (with age restrictions). Claims must include FD-263 forms unless surgery is urgent/emergent or geographically waived.
Effective November 1, 2026, site of care medical necessity reviews apply to the listed surgical procedures only when they are performed in an outpatient hospital setting. Use of a hospital outpatient department instead of an ambulatory surgery center or physician office may be considered medically necessary when one or more listed criteria are met, such as no geographically accessible in-network ASC that has the necessary equipment, a procedure that requires discontinuing medications that necessitate inpatient monitoring or treatment, ASA Physical Status III or higher, or a BMI over 40. Hospital outpatient use is considered not medically necessary when the criteria are not met.
This surgical site of care policy sets criteria for when a hospital outpatient department may be considered medically necessary instead of an ambulatory surgery center or physician office for listed surgical procedures. Hospital outpatient use may be considered medically necessary when one or more criteria are met, such as no qualifying in-network ASC within 25 miles that can provide the necessary care, an ASA Physical Status Classification of III or higher, a body mass index over 40, or a surgery expected to last longer than 3 hours. Use of a hospital outpatient department instead of an ASC or physician office is considered not medically necessary when the criteria are not met. The procedure may require prior authorization separately under its own medical policy.
Effective October 1, 2026, Highmark removed 32 hysterectomy-related CPT codes from its prior authorization list. Billing teams should update authorization workflows to reflect that these procedures no longer require prior authorization for Highmark members.
Independence Blue Cross updated MA11.077j to add three new ICD-10 diagnosis codes effective 10/01/2026: QA1.790 (Familial cancer syndrome with pathogenic BRCA1 mutation), QA1.791 (Familial cancer syndrome with pathogenic BRCA2 mutation), and QA1.792 (Li Fraumeni syndrome). These codes now qualify for coverage of prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy procedures under Medicare Advantage plans.
Independence Blue Cross updated policy 11.08.19t with three new ICD-10 diagnosis codes effective 10/01/2026 to support coverage determinations for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy in patients with familial cancer syndromes. The billing team must ensure these new codes (QA1.790, QA1.791, QA1.792) are recognized in billing systems and attached to claims for these procedures when applicable.
Policy 7.01.84 sets the criteria for gender affirming surgery and treatments for commercial and Medicare Advantage members, with a current effective date of May 21, 2026. Gender affirming surgery may be considered medically necessary when the member has reached age 18 (except for mastectomy), one letter from a qualified professional documents gender dysphoria that is marked and sustained for at least 6 months, and the other general criteria are met. Breast augmentation, hysterectomy, gonadectomy and genital reconstructive surgery each require six months of continuous hormone therapy or a documented contraindication to hormone therapy, and voice modification and voice therapy require review by a Health Plan Behavioral Health Medical Director.
Independence Blue Cross updated MA11.077i to MA11.077j, adding nine new ICD-10 diagnosis codes effective 10/01/2025 to support coding for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy procedures. The policy itself was reissued on 04/01/2026 to reaffirm the Company's continuing coverage position; no changes to medical necessity criteria or procedure coverage occurred.
Independence Blue Cross updated MA11.077i to MA11.077j, adding nine new ICD-10 diagnosis codes (effective 10/01/2025) related to inflammatory breast cancer, fallopian tube conditions, and prophylactic surgery encounters. The policy reissued on 04/01/2026 to reaffirm the Company's continuing position on prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy coverage criteria without substantive changes to medical necessity standards.
Independence Blue Cross has reissued policy 11.08.19s (now version 11.08.19t) for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy with updated ICD-10 codes effective 10/01/2025. Nine new diagnosis codes have been added to support coverage determinations, including codes for inflammatory breast cancer, genetic susceptibility to fallopian tube malignancy, and family/personal history of fallopian tube cancer. The coverage criteria and medical necessity standards remain unchanged from the prior version.
This Premera medical policy and coding update lists changes from October 2021. Effective October 1, 2021, the Diagnosis and Treatment of Sacroiliac Joint Pain policy 6.01.527 replaced policy 6.01.23, and injection of an anesthetic to diagnose sacroiliac joint pain was removed. Site of service review was added for medical necessity on single-level cervical decompression and fusion and single-level lumbar fusion, effective January 7, 2022, and coding changes effective October 1, 2021 added review for investigative care, medical necessity or prior authorization to several codes, including 27280, C9084, Q2054, J9318, J9319 and J1426.
This Premera medical policy and coding update lists changes from November 2021. Effective November 5, 2021, the Allograft Injection for Degenerative Disc Disease policy 7.01.166 is investigational, and a new Non-covered Experimental/Investigational Services policy 10.01.533 lists services that require investigative review. Effective January 7, 2022, single-level cervical and lumbar spine procedures gained site of service review, and effective February 4, 2022, ASAM codes H0031, H0032, H2014, H2019, S5108, S5109, S5110 and S5111 require medical necessity and prior authorization review for individual plans.
Effective January 22, 2026, gender reassignment surgery is considered medically appropriate for members age 18 or older who have referral letters from two qualified NYS licensed health professionals, and the policy lists the covered surgeries and services for Medicaid Managed Care Plan and Health and Recovery Plan members. The January 22, 2026 annual review moved the hormone therapy criteria to Pharmacy policies with policy intent unchanged, and a March 20, 2026 policy edit revised policy statement references for alignment, also with intent unchanged.
Independence Blue Cross reissued policy 11.08.19s on 04/01/2026 to reaffirm coverage for prophylactic mastectomy, oophorectomy/salpingo-oophorectomy, and hysterectomy in high-risk and moderately increased-risk individuals. Nine new ICD-10 diagnosis codes were added effective 10/01/2025 to support claims related to inflammatory breast cancer, genetic susceptibility to fallopian tube malignancies, and family/personal history of fallopian tube neoplasms. No changes to coverage criteria, CPT codes, or billing requirements were made.
Watch 58263
Get one email when a payer policy names 58263, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.
See every payer rule for 58263
Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 58263 in one place.
Get alerts for changes like this
Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.