58573 prior authorization | Premera Blue Cross of Washington

58573, Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) These criteria do not imply or guarantee approval., is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code: 58573
Description: Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) These criteria do not imply or guarantee approval.
Source: Clinical Review by Code List PBCWA, Pg 360 Original policy

Premera Blue Cross of Washington prior authorization

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