CLEAR COVERAGE HYSTERECTOMY CHECKLISTS Click on the link below to access the checklist sheet. Abnormal Uterine Bleeding Adenomyosis Chronic Abdominal or Pelvic Pain Endometriosis Fibroids General Guidelines Pelvic Inflammatory Disease or Tubo-Ovarian Abcess Uterine Prolapse
ABNORMAL UTERINE BLEEDING NOTE: This checklist is intended to be used as a guideline to assist non-clinical staff in requesting preauthorizations through Clear Coverage. It is not to be used as a form for faxing information to the health plan regarding a preauthorization request. This does not guarantee authorization Abnormal uterine bleeding Premenopausal Postmenopausal Vagina and cervix normal by physical exam Most recent cervical cytology normal (or treated) PREMENOPAUSAL ONLY (see next page for postmenopausal): Thyroid disease excluded (by history, physical exam or testing) HCG planned prior to procedure; OR Sterilization by history; OR Sonohysterogram or ultrasound negative for endometrial lesion Bleeding interferes with ADL s; OR Anemia unresponsive to iron treatment > 12 weeks Treatment: Progestin or oral contraceptive pill x 3 consecutive cycles; and/or Levonorgestrel-releasing intrauterine system; and/or Tranexamic acid x 3 consecutive cycles; and/or Endometrial ablation or resection
ABNORMAL UTERINE BLEEDING Continued bleeding after treatment Age > 45 Endometrium normal By endometrial biopsy; and/or By hysteroscopy with D & C POSTMENOPAUSAL ONLY: Endometrium normal within last 3 months by biopsy and ultrasound Currently taking hormone replacement therapy Continued bleeding after, Change in hormone replacement therapy; OR Discontinuation of hormone replacement therapy
ADENOMYOSIS Adenomyosis suspected by imaging Symptoms: Pelvic or abdominal pain or discomfort and other etiologies excluded; OR Urinary frequency or urgency and other etiologies excluded; OR Dyspareunia Abnormal bleeding and if so: Vagina and cervix normal by physical exam Other etiologies of bleeding excluded AND: Bleeding interferes with ADL s; OR Anemia unresponsive to iron treatment > 12 weeks Treatment: NSAIDS > 8 weeks; OR GnRH agonist > 8 weeks; OR Depot or oral contraceptive pill > 8 weeks Continued symptoms/findings after treatment Most recent cervical cytology normal or treated per guidelines
ADENOMYOSIS HCG planned prior to procedure; OR Sterilization by history; OR
CHRONIC ABDOMINAL or PELVIC PAIN Chronic abdominal or pelvic pain of unknown etiology History and physical examination completed CBC normal Urinalysis or urine culture normal Cervical cytology normal (or treated) HCG planned prior to procedure; OR Sterilization by history; OR Ultrasound non-diagnostic for etiology of pain Testing non-diagnostic for etiology of pain: CT or MRI; and/or Diagnostic laparoscopy Treatment: NSAIDS > 4 weeks Depot or oral contraceptive > 8 week GnRH agonist > 8 weeks Antibiotic treatment X one course Continued pain after treatment
ENDOMETRIOSIS Endometriosis by laparoscopy Treatment: GnRH agonist > 8 weeks; and/or Depot or oral contraceptive > 8 weeks; and/or Danazol > 8 weeks Continued symptoms after treatment Most recent cervical cytology normal (or treated) HCG planned prior to procedure; OR Sterilization by history; OR
FIBROIDS Fibroids by Ultrasound Premenopausal Postmenopausal Symptoms: Uterine size doubled by ultrasound within 1 year; OR Ureteral compression by imaging; OR Pelvic or abdominal pain or discomfort and other etiologies excluded; OR Urinary frequency or urgency and other etiologies excluded; OR Dyspareunia; OR Abnormal bleeding, and if so: Vagina and cervix normal by physical exam; AND Other etiologies of bleeding excluded AND: Bleeding interferes with ADL s; OR Anemia unresponsive to iron treatment > 12 weeks Most recent cervical cytology normal or treated per guidelines If premenopausal: HCG planned prior to procedure; OR Sterilization by history; OR
Premenopausal Postmenopausal Diagnosis and/or chief complaint: Chronic abdominal or pelvic pain of unknown etiology Endometriosis by laparoscopy Abnormal uterine bleeding Adenomyosis suspected by imaging Fibroids by ultrasound Uterine prolapse Pelvic Inflammatory Disease (PID) Tubo-ovarian abcess Symptoms/Findings/Testing: History and physical examination completed CBC normal Urinalysis or urine culture normal Pelvic pressure Pelvic pain or discomfort and other etiologies excluded Acute Pelvic Inflammatory Disease > 2 episodes by H & P exam
Abdominal tenderness Persistent adnexal mass Temperature > 100.4 Tubo-ovarian mass by imaging WBC > normal Stress incontinence Urinary frequency or urgency (other etiologies excluded) Ulceration with bleeding or spotting by physical exam Vaginal splinting Uterine size doubled by ultrasound within 1 year Ureteral compression by imaging Dyspareunia Abnormal bleeding, and if so: Vagina and cervix normal by physical exam Other etiologies of bleeding excluded Bleeding interferes with ADL s Anemia unresponsive to iron treatment > 12 weeks Most recent cervical cytology normal (or treated) Negative HCG HCG planned prior to procedure Sterilization by history
Ultrasound non-diagnostic for etiology of pain Testing non-diagnostic for etiology of pain: CT or MRI Diagnostic laparoscopy Treatment: NSAIDS > 4 weeks Depot or oral contraceptive > 8 weeks GnRH agonist > 8 weeks Antibiotic treatment X one course Danazol > 8 weeks Worsening symptoms during IV treatment Continued pain after treatment
PELVIC INFLAMMATORY DISEASE/ TUBO-OVARIAN ABCESS Pelvic Inflammatory Disease: Pelvic pain Acute Pelvic Inflammatory Disease > 2 episodes by by H & P exam Infection documented > episode by positive culture Most recent cervical cytology normal (or treated) HCG planned prior to procedure Tubo-Ovarian Abscess: Tubo-ovarian abscess by imaging Ectopic pregnancy excluded by negative HCG Symptoms: Pelvic pain; and/or Abdominal tenderness; and/or Persistent adnexal mass; and/or Temperature > 100.4; and/or WBC > normal Worsening symptoms during IV treatment
UTERINE PROLAPSE Uterine prolapse by physical examination Second Degree Third Degree Pelvic pressure by history Pelvic pain by history Stress incontinence by history Ulceration with bleeding or spotting by physical examination Vaginal splinting Most recent cervical cytology normal (or treated) HCG planned prior to procedure; OR Sterilization by history; OR