CurrentColorado Rocky Mountain Health PlansPolicy CS343OH.D

Surgery of the Hand or Wrist (Ohio)

Medical policy governing coverage and medical necessity review for hand and wrist surgical procedures for members in the state of Ohio. Applies to providers requesting authorization or adjudication of related procedures under the payer's Ohio Medicaid product.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySurgery of the Hand or Wrist (Ohio)

Policy CodePolicy CS343OH.D

Change TypeRoutine review — no change to coverage guidelines

Effective DateSep 1, 2025

Next Review Date

Key ActionUse InterQual clinical criteria to support prior authorization requests for listed hand and wrist procedures.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

InterQual-basedPrimary clinical criteria source

Ohio-onlyState scope

≈20 CPTsReference codes

09/01/2025Effective

Coverage and Medical Necessity Criteria

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Medically necessary when InterQual criteria are met

Covered when ALL of the following are met per InterQual criteria:

InterQual criteria: Procedure-specific InterQual CP criteria (for example: Arthroplasty — CMC, MCP, PIP; Arthroscopy or arthroscopically assisted wrist surgery; Diagnostic wrist arthroscopy +/- synovial biopsy; Wrist joint replacement; Removal or revision of wrist arthroplasty) must be met to consider the requested hand or wrist surgery medically necessary.see InterQual

Provider must reference and supply the applicable InterQual CP documentation to support prior authorization and medical necessity review. InterQual link: https://www.uhcprovider.com/content/provider/en/policies-protocols/sec_interqual-clinical-criteria.html

The inclusion of a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is a covered health service. Benefit coverage and any reimbursement rights are governed by applicable federal, state, and contractual requirements and laws, which may mandate coverage for specific services. Providers should not assume that listing of a code in this policy guarantees payment or coverage; other policies, guidelines, and applicable rules may affect coverage determinations.

This policy underwent routine review effective 09/01/2025. There is no change to coverage guidelines in this version; the previous policy version CS343OH.C has been archived.

Applicable Procedure Codes

Applicable CPT Codes (part 1)CPT

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.

Applicable CPT Codes (part 2)CPT

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.
26536	Arthroplasty, interphalangeal joint; with prosthetic implant, each joint.
29840	Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure).
29843	Arthroscopy, wrist, surgical; for infection, lavage and drainage.
29844	Arthroscopy, wrist, surgical; synovectomy, partial.
29845	Arthroscopy, wrist, surgical; synovectomy, complete.

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Provider Responsibilities and Prior Authorization

Prior Authorization

InterQual required for medical necessity review

InterQual Clinical Criteria are required and will be used as the basis for medical necessity determinations during prior authorization and medical necessity reviews. Providers should reference and apply the InterQual criteria when submitting authorization requests for hand and wrist surgical procedures.

Authorization requests will be evaluated using InterQual Clinical Criteria
If InterQual does not have applicable criteria, UnitedHealthcare Medical Policies or Coverage Determination Guidelines may be used

Documentation Required

Provider documentation and submission requirements

Providers must ensure authorization requests include documentation that demonstrates how the patient meets the InterQual criteria and other policy-specific clinical requirements. Incomplete documentation or failure to follow the required criteria may result in delay or denial of authorization.

Include relevant clinical history, imaging, prior conservative treatments, and operative indications
Ensure submitted codes and documentation align with the InterQual criteria cited

Note

Reference governing rules

Decisions about coverage are governed by federal law, state rules (including Ohio Administrative Code where applicable), and the member's contractual benefit plan. If there is a conflict between this policy and federal, state (OAC), or contractual requirements, those governing rules take precedence.

Verify applicable federal, state (OAC), and contract terms before relying on this policy
This policy is informational and does not replace benefit plan language

Billing Rule

Coding listing is not coverage guarantee

Listing a procedure or diagnosis code in this policy is for reference only and does not guarantee coverage or payment. Benefit coverage and payment depend on the member's benefit plan, applicable federal or state law, and medical necessity as determined by InterQual and plan rules.

Use the code list as a reference; confirm coverage under the member's benefit plan
Inclusion of a code is not a guarantee of reimbursement or claim payment

Clinical Background

Surgery of the hand or wrist is recognized as proven and medically necessary in certain circumstances. Covered procedures may include arthroplasty (with or without prosthetic implant), arthroscopy, synovectomy, joint replacement, revision or removal of implants, and other reconstructive or diagnostic procedures when clinically indicated. Determinations of medical necessity for specific hand and wrist surgeries are made using the referenced InterQual clinical criteria; providers must reference the procedure-specific InterQual entry for the detailed clinical indications and documentation requirements that justify surgery.