UnitedHealthcare: Mar–May 2026 Orthopedics & Musculoskeletal Policy Revisions

UnitedHealthcare updated multiple orthopedics and musculoskeletal policies effective March–May 2026, including revisions to hip and knee surgery (effective Mar. 1), spinal fusion/decompression and vertebral body tethering for scoliosis (effective Apr. 1), and TMJ treatment (effective Mar. 1). Lower extremity endovascular procedures appear twice — updated effective Mar. 1 and revised effective May 1 — indicating sequential edits to coverage or coding guidance; embolization for pelvic congestion was updated effective Mar. 1. Preventive care services and Category III code guidance were revised effective Apr. 1, 2026. The bulletin notes timing and status changes but does not list specific CPT/HCPCS codes or the detailed wording of each revision; providers should review the full policy texts for coding and prior authorization impacts.

UnitedHealthcare: RSA, Sinus Tarsi Implants, Humeral Lengthening Deemed Unproven

UnitedHealthcare’s March 1, 2026 revision to MDC 08 (Orthopedics & Musculoskeletal) classifies radiostereometric analysis (RSA) codes (0347T–0350T), subtalar sinus tarsi/arthroereisis codes (0335T, 0510T, 0511T, S2117), and humeral lengthening with externally controlled intramedullary devices (0594T) as unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. RSA is acknowledged as a precise research tool but lacks data showing routine clinical benefit versus standard imaging. Sinus tarsi implants show heterogeneous, low-quality evidence with variable complication and removal rates, and are not supported for any indication. Humeral lengthening procedures have limited case-series data with substantial complication rates, and comparative benefit over other techniques remains unestablished.

Premera MDC‑08 Update: New Orthopedic Device Codes (0594T, 27713) — Mar 2026

Premera Blue Cross revised MDC 08 (Orthopedics & Musculoskeletal) effective 2026-03-01 to list numerous CPT and HCPCS codes designated as non-covered/experimental, with several new codes effective 01/01/2026. Newly referenced intramedullary lengthening device codes include 0594T (humerus osteotomy with externally controlled intramedullary lengthening device) and CPT 27713 (tibia osteotomy with such a device). The update also highlights intrafacet implant codes (0219T–0222T), xenograft and bone-substitute procedure codes (0737T, 0707T), and device/implant HCPCS (e.g., C1737), and consolidates advanced imaging, analytic, and AI-related codes tied to musculoskeletal assessment. Providers should note these additions reflect payer scrutiny of contemporary limb-lengthening technologies, implants, and imaging/analytics and that several codes are newly effective 01/01/2026.

Cigna MDC 08 Policy 0558: New CPT Category III Codes Added (4/15/2026)

Effective 4/15/2026, Cigna updated Medical Coverage Policy 0558 (MDC 08: Orthopedics & Musculoskeletal) to enumerate new CPT Category III and other recent procedure codes and short descriptions in the effective-date note. Examples include codes for biodegradable hydrogel instillation, autologous muscle cell therapy harvesting/administration, first carpometacarpal joint prosthetic arthroplasty (1003T), and device/technique-specific services (0990T–1025T). The policy references CPT® 2025 for coding and situates these additions within Cigna’s broader musculoskeletal coverage resources (e.g., Miscellaneous Musculoskeletal Procedures, Subtalar Joint Implantation), but the excerpt does not include coverage determinations or medical necessity language. Use the effective-date note and related musculoskeletal policies for coverage criteria and benefit guidance.

Anthem: Bevacizumab Coverage Updated for Angiosarcoma and Solitary Fibrous Tumor

Anthem updated its bevacizumab non‑ophthalmologic clinical criteria (CC-0107) effective 2026-03-01 to incorporate NCCN 2A recommendations for select soft tissue sarcomas. Bevacizumab is specified as covered as a single agent for angiosarcoma and in combination with temozolomide for solitary fibrous tumor, both retained at NCCN 2A (consensus but not highest-level evidence). The revision appears in the broader bevacizumab indication table alongside other tumor-specific requirements and includes updated HCPCS/Q-code mapping for bevacizumab biosimilars and related coding notes. Providers should use the listed ICD-10 ranges (e.g., C49.0–C49.9) and the specified regimen contexts when submitting authorization requests.

Cigna Update: Enumerated Vitamin D Testing Indications, Limits & Exclusions

Effective 6/15/2026, Cigna’s Vitamin D Testing policy (0526) defines explicit, enumerated medical-necessity indications for total 25(OH)D (CPT 82306/0038U) and for active 1,25(OH)2D (CPT 82652), and sets repeat-testing limits. Total 25(OH)D testing is authorized only for listed conditions (e.g., rickets/osteomalacia, CKD, malabsorption, hyperparathyroidism, granulomatous disease, certain medications, extremes of age, prior deficiency, toxicity, specified genetic disorders), with repeat testing allowed only every 3 months when criteria are met. Active 1,25(OH)2D testing is limited to separate, specific indications (e.g., CKD, phosphate-wasting disorders, oncogenic osteomalacia, granulomatous or inflammatory diseases), and combined billing of both assays is expressly not covered. The policy reiterates that vitamin D testing for general population screening or unlisted indications is not covered; coverage decisions remain subject to plan language and applicable law.

Premera: Orthopedics & Stem Cell Policies Open for Comment — Mar 5, 2026

Premera-Blue Cross has posted a package of policies related to orthopedics and musculoskeletal care for stakeholder comment, with feedback due by March 5, 2026. Policies open for review include Suture Button Suspensionplasty for thumb CMC osteoarthritis (7.01.176), Knee Arthroplasty in Adults (7.01.550), Hip Arthroplasty in Adults (7.01.573), Shoulder Arthroplasty (7.01.590), and Orthopedic Applications of Stem Cell Therapy (8.01.52). The document is a request for comment only and does not include proposed coverage language, clinical criteria, CPT coding, or utilization management details. Providers should submit feedback by the March 5, 2026 deadline if they wish to influence these policy areas.

Ohio: Prolotherapy and PRP Declared Not Medically Necessary — Mar 2026

UnitedHealthcare Ohio policy CS103OH.C (March 1, 2026) now explicitly states prolotherapy (including hypertonic dextrose) and platelet-rich plasma (PRP) are unproven and not medically necessary for any musculoskeletal indication. The revision retains a detailed evidence review noting heterogeneous preparations, small/variable trials, inconsistent outcomes across knee OA, tendinopathies, rotator cuff disease, plantar fasciitis and low back pain, and limited safety/long-term data. Professional society guidance and high-quality RCTs showing no consistent benefit (e.g., Bennell et al., 2021) are cited to support the blanket noncoverage. Providers should continue to refer to related Ohio policies (e.g., skin and soft tissue substitutes) for other biologic injections.

Ankle Surgery Coverage Now Governed by InterQual® CP Modules — KY (Effective 3/1/26)

Effective March 1, 2026, UnitedHealthcare Kentucky (CS340KY.10) now links medical necessity determinations for ankle surgery directly to InterQual® CP: Procedures modules for Arthrodesis (talotibial), Arthroscopy (surgical), Arthrotomy, and Total Joint Replacement (ankle). The policy no longer lists standalone clinical criteria in the text; reviewers must use the specified InterQual® procedural modules to authorize and review the listed ankle procedures. Applicable CPT codes are organized under the four procedure headings to align coding with the InterQual® modules. This update applies to Kentucky members and makes InterQual® the operative standard for evaluating these ankle surgeries.

UnitedHealthcare: 78399 Added for Musculoskeletal Diagnostic Nuclear Medicine

UnitedHealthcare’s March 2026 Radiologic Diagnostic Procedures Applicable Codes section now explicitly lists unlisted diagnostic nuclear medicine codes by anatomic system, including 78399 for musculoskeletal studies. The update enumerates other unlisted codes (78299, 78499, 78599, 78699, 78799) for GI, cardiovascular, respiratory, nervous system, and genitourinary procedures alongside specific pulmonary nuclear medicine CPTs (78579, 78580, 78582, 78597, 78598). No clinical criteria, documentation requirements, billing guidance, or frequency limits are included in the extract; the change is limited to code inclusion. Providers should treat 78399 as the designated unlisted code for musculoskeletal diagnostic nuclear medicine when no specific CPT exists and anticipate needing to supply supporting documentation per usual unlisted-code practice.