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    Largest insurer requiring preauthorization for some hysterectomies

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    In the latest volley in the ongoing controversy regarding the safety of some forms of hysterectomy, the country’s largest insurer will soon begin requiring prior authorization for many of the procedures. The action, taken by UnitedHealthCare, takes effect April 6, 2015 and does not apply to outpatient vaginal surgeries.

    In a Medical Policy Bulletin to physicians and hospitals, UnitedHealthCare cites policy statements from AAGL and the American College of Obstetricians and Gynecologists as well as a Cochrane review and several meta-analyses to support its belief that “a vaginal approach to hysterectomy has fewer complications, requires a shorter hospital stay and is associated with better outcomes than a laparoscopic or abdominal approach.”

    The CPT codes impacted by the new requirement, and listed in a Network Bulletin issued in January, apply to abdominal laparoscopic, vaginal, and laparoscopic-assisted vaginal hysterectomy. No prior authorization is needed for vaginal hysterectomies performed on an outpatient basis. If prior authorization is required, failure to obtain it will result in an administrative claim denial, according to the Bulletin.

    The tightening of controls on hysterectomies comes in the wake of a warning from the Food and Drug Administration in November 2014 about the use of morcellators during laparoscopic hysterectomies because of concern about the potential for seeding of undetected uterine sarcomas. Morcellation is not performed during vaginal hysterectomy.

    Recommended: What you need to know about power morcellation for fibroids

    In its coverage of the action by UnitedHealthcare, The Wall Street Journal speculated that because the company covers 40 million customers in the United States, it “could trigger broad changes in clinical practice.” 

    headshot of Jon I Einarsson, MD, PhD, MPHReflecting on the potential impact of the preauthorization guidelines, Contemporary OB/GYN Deputy Editor Jon I. Einarsson, MD, PhD, MPH, who is an expert in minimally invasive gynecologic surgery, pointed out that a vaginal procedure is the most cost-effective method of hysterectomy, but that mode of access is not suitable for all patients. “It’s unfortunate,” he said, “when an insurance carrier interferes with the physician-patient decision-making process.”

    Dr. Einarsson also noted that there is no convincing evidence that vaginal hysterectomy requires a shorter hospital stay than a laparoscopic hysterectomy, since both are minimally invasive options. Data from randomized trials show that patients have significantly higher levels of pain in the immediate postoperative period after a vaginal hysterectomy as compared with the laparoscopic approach.

    Regarding the controversy about morcellation, he said that during vaginal hysterectomy involving a large uterus, morcellation is commonly done vaginally with a knife. According to Dr. Einarsson, “The evidence shows that the higher mortality rate for morcellation is mostly associated with use of vaginal morcellation with a knife and not with use of traditional mechanical morcellators. Because any tissue disruption can potentially spread undetected cancers, we [at Brigham & Women’s] have been advocating for contained tissue extraction when morcellation of any kind is performed, but that is very difficult to accomplish with a vaginal approach, while very feasible when approaching a hysterectomy laparoscopically.” 

    NEXT: What's the impact of bariatric surgery on pregnancy outcomes?

    Judith M. Orvos, ELS
    Judith M. Orvos, ELS, is a a BELS-certified medical writer and editor and an editorial consultant for Contemporary OB/GYN.
    Miranda Hester
    Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

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