All PlansPrior AuthHigh impact
Hysterectomy
Regence BlueShield·OB-GYN·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jul 7, 2026
Summary
This new hysterectomy prior authorization policy (effective July 1, 2026) establishes specific medical necessity criteria for hysterectomy procedures across nine clinical indications. Billing teams must now obtain prior authorization and ensure clinical documentation supports one of nine approved conditions before submitting claims. Claims submitted without meeting these criteria or proper documentation will be denied.
Action Required
By July 1, 2026: Billing team must implement prior authorization requirement for all hysterectomy CPT codes (58150, 58152, 58180, 58200, 58210, 58270, 58275, 58280, 58285, 58290-58294, 58550, 58570-58574) in billing software and claim submission workflows. Providers must document clinical evidence supporting one of nine covered indications: abnormal uterine bleeding, adenomyosis, cervical intraepithelial neoplasia, chronic pelvic inflammatory disease, endometriosis, leiomyoma, pelvic adhesive disease, pelvic pain (specified scenarios), or pelvic venous congestion. Update encounter forms and EMR templates to include required documentation checklist per policy section "Required Documentation." Ensure all pre-authorization requests include supporting clinical records (history/physical, imaging results, conservative treatment attempts, contraindication documentation). Train providers on specific criteria for each indication—particularly the multi-step requirements for abnormal uterine bleeding (prior imaging + failed hormonal therapy + failed conservative surgery) and endometriosis (confirmed diagnosis + documented conservative surgery failure). Flag any claims lacking required documentation or failing to meet criteria for denial and member notification. Failure to obtain authorization or provide complete documentation will result in claim denials.