OB/GYN Prior Authorization and Denial Guide
Global obstetric package billing rules, modifier -25 documentation standards for same-day antepartum visits, gynecologic surgery prior authorization requirements, and denial patterns for colposcopy, LEEP, and hysterectomy. Grounded in Aetna Medical Policy for hysterectomy and uterine procedures, UHC CDG OB/GYN Surgery, ACOG clinical practice bulletins, and CMS global surgery rules.
Global OB package (CPT 59400, 59510, 59610, 59618): the global obstetric package includes all antepartum care, the delivery, and postpartum care within defined timeframes. Services beyond the global package — high-risk antepartum visits beyond the included count, ultrasounds, non-stress tests, antepartum hospitalization — are billed separately. When a patient transfers care in the middle of pregnancy, the delivering physician bills only the services actually provided using component billing codes (antepartum care, delivery, and postpartum separately). CO-97 bundling denials are common when separately billable services are not distinguished from the global package content.
Hysterectomy: prior authorization is required by most commercial payers. Aetna Medical Policy for hysterectomy requires documentation of the indication and conservative treatment failure documentation for benign indications — abnormal uterine bleeding requires documented failure of medical management (hormonal therapy, endometrial ablation consideration), and fibroids require documented symptom burden (pain, pressure, AUB) and, for some payers, size or number thresholds. Laparoscopic hysterectomy requires the same documentation as open hysterectomy. Colposcopy and LEEP do not typically require prior authorization but are subject to frequency limits and diagnosis-code matching requirements.