Medicaid reimbursement is available for the performance of
hysterectomies with the following restrictions:
(1) Hysterectomy procedures must comply with
hysterectomy performed solely for the purpose of rendering a woman permanently
incapable of reproducing, whether performed as a primary or secondary
procedure, is not reimbursable by Medicaid.
(3) The acknowledgement of the hysterectomy
information statement must be signed by the member, or member's representative,
but is not required where the member is already sterile or where a
life-threatening emergency situation exists. Where the hysterectomy is
performed on an already sterile member, the physician who performs the
hysterectomy must certify in writing that the member was already sterile at the
time the hysterectomy was performed and state the cause of the
(4) Where the
hysterectomy is performed under a life-threatening emergency situation, the
physician who performed the hysterectomy must certify in writing that the
hysterectomy was performed under a life-threatening emergency situation and
that prior acknowledgement was not possible. The physician must include a
description of the nature of the life-threatening emergency.
(5) The individual must be informed orally
and in writing that this procedure will render her permanently incapable of
reproducing, and she must sign a written acknowledgement of receipt of this
(6) Hysterectomy is
subject to prior authorization. Where the hysterectomy is performed under a
life-threatening emergency situation, the physician shall notify the office
within forty-eight (48) hours of the procedure, not including Saturday, Sunday,
and legal holidays, to obtain prior authorization.
(7) All appropriate documentation must be
attached to the claim and to claims for directly related services before
reimbursement may be made.