Why UHC Denies Hysterectomy
Conservative management not exhausted (hormonal therapy, ablation)
Uterine size does not meet threshold
Alternative less invasive procedures not tried
Know UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
Building Your Medical Necessity Argument
Document failure of hormonal management
Note uterine size and symptom severity
Explain why less invasive alternatives are not appropriate
Reference impact on quality of life and functional status
P2P Call Tips for UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- ACOG Practice Bulletin on Hysterectomy
- AAGL Practice Guidelines for Hysterectomy
Relevant CPT Codes
Specialty: Gynecology
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