CurrentColorado Rocky Mountain Health PlansPolicy CS343.I

Surgery of the Hand or Wrist

Defines medical policy coverage stance for surgical procedures of the hand and wrist for Colorado Rocky Mountain Health Plans members, referencing InterQual criteria for clinical necessity and providing applicable CPT/HCPCS procedure codes. Excludes certain states where state-specific policies apply.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySurgery of the Hand or Wrist

Policy CodePolicy CS343.I

Change TypeMaterial and non-material edits

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionConfirm medical necessity using InterQual CP: Procedures and submit required medical records for prior authorization as needed.

SourceLink

POLICY UPDATE CHANGES

Added language that this Medical Policy does not apply to the state of North Carolina; refer to the state-specific policy version.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria for coverage.

Removed content/language pertaining to the state of Louisiana.

>10Listed applicable procedure codes

InterQualReferenced clinical criteria set

MultipleStates excluded

1Policy number

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Coverage Criteria — Hand and Wrist Surgery

Medically necessary per InterQual

Covered when ALL of the following are met per InterQual CP: Procedures for the listed surgeries

InterQual-based criteria: Member meets the applicable InterQual CP: Procedures criteria for the specific hand or wrist surgery (e.g., Arthroplasty, Carpometacarpal (CMC) joint, thumb; Arthroplasty, Metacarpophalangeal (MCP) joint, digits; Arthroplasty, Proximal Interphalangeal (PIP) joint, fingers; Arthroscopy or arthroscopically assisted surgery, wrist; Arthroscopy, diagnostic, with or without synovial biopsy, wrist; Joint replacement, wrist; Removal or revision of arthroplasty, wrist).see InterQual

Policy references InterQual CP: Procedures for detailed inclusion/exclusion criteria and clinical thresholds; InterQual criteria determine medical necessity.

This Medical Policy does not apply to all U.S. states. For members in states listed below, refer to the state-specific "Surgery of the Hand or Wrist" policy or guideline identified for that state rather than this document: Idaho, Indiana, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, Tennessee. Where a state-specific policy is named, that policy governs coverage determinations for members in that state.

The presence of a procedure or diagnosis code in this policy is provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non-covered health service, nor does inclusion guarantee reimbursement or payment. Benefit coverage is determined by federal, state, and contractual requirements and applicable law; other policies or guidelines may also affect coverage determinations.

Applicable Procedure Codes

Applicable procedure codesCPT

25441	Arthroplasty with prosthetic replacement; distal radius.
25442	Arthroplasty with prosthetic replacement; distal ulna.
25443	Arthroplasty with prosthetic replacement; scaphoid carpal (navicular).
25444	Arthroplasty with prosthetic replacement; lunate.
25445	Arthroplasty with prosthetic replacement; trapezium.
25446	Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist).
25449	Revision of arthroplasty, including removal of implant, wrist joint.
26530	Arthroplasty, metacarpophalangeal joint; each joint.
26531	Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint.
26535	Arthroplasty, interphalangeal joint; each joint.

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Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization: Services may require prior authorization and medical necessity review using InterQual® criteria for hand and wrist procedures. Providers should obtain authorization before scheduling non-emergent procedures when required by the plan.

InterQual® CP criteria apply (see Coverage Rationale)
Prior authorization may be required for procedures listed under InterQual®

Note

Provider Contact for Supplemental Information

Providers may be contacted for supplemental information to support medical necessity determinations. Ensure the ordering or performing provider is available to respond to requests for clinical clarification.

Documentation Required

Background

Surgical procedures of the hand and wrist — including arthroplasty, arthroscopy, joint replacement and revision procedures — are established interventions for specific diagnoses and indications. This policy relies on the InterQual Clinical Practice (CP) "Procedures" criteria to determine medical necessity for the various hand and wrist surgeries addressed; when the InterQual criteria are met, the procedure is considered medically necessary under this policy. Note that while surgeries themselves are not regulated by the U.S. Food and Drug Administration, devices or implants used during these procedures may require FDA clearance or approval and such device status does not by itself determine coverage.

Definitions

Procedures vs. FDA regulation

ScopeSurgeries of the hand or wrist are procedures and are not regulated by the U.S. Food and Drug Administration (FDA).

Device approvalDevices and instruments used during hand or wrist surgery may require FDA approval.

Purpose of sectionThis information is for informational purposes only; FDA approval alone is not a basis for coverage.

ReferenceFor more information on device approvals, refer to the FDA PMN database: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm (Accessed February 13, 2025).