Currentsierra health and lifePolicy 2026T0551AA

Surgery of the Elbow (Arthroscopy and Arthroplasty) — Coverage Criteria

Defines clinical coverage rationale and applicable procedure/diagnosis codes for elbow surgeries (arthroscopy and joint replacement) as applied to Sierra Health and Life members under UnitedHealthcare standard benefit plans.

Policy Summary

Payersierra health and life

PolicySurgery of the Elbow (Arthroscopy and Arthroplasty) — Coverage Criteria

Policy CodePolicy 2026T0551AA

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain and document medical records demonstrating the member meets InterQual clinical criteria; submit prior authorization if required by the member's plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InterQualExternal criteria used for medical necessity

14 codesProcedure codes included

Commercial & ExchangePlan applicability

Template updatePolicy history note

Coverage Criteria

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Medical necessity per InterQual

Covered when member meets InterQual clinical criteria for the listed procedures.

InterQual-based coverage: Coverage for elbow arthroscopy and arthroplasty is determined by meeting the InterQual CP: Procedures criteria for one of the listed procedure groups: Arthroscopy, Diagnostic +/- Synovial Biopsy (Elbow); Arthroscopy, Surgical (Elbow); Joint Replacement (Elbow); or Removal or Revision of Arthroplasty (Elbow).

Refer to InterQual for the specific clinical requirements and detailed criteria; providers may need to submit records demonstrating InterQual criteria are met.

The list of procedure and diagnosis codes in this policy is provided for reference only. Listing of a code does not imply the service is covered; benefit coverage for health services is governed by the member specific benefit plan document and applicable laws. The inclusion of a code in this policy does not guarantee reimbursement or claim payment and other policies or guidelines may apply.

Procedure and Diagnosis Codes

Applicable CPT Codes (listed)CPT

24360	Arthroplasty, elbow; with membrane (e.g., fascial)
24361	Arthroplasty, elbow; with distal humeral prosthetic replacement
24362	Arthroplasty, elbow; with implant and fascia lata ligament reconstruction
24363	Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total elbow)
24365	Arthroplasty, radial head
24366	Arthroplasty, radial head; with implant
24370	Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component
24371	Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component
29830	Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure)
29834	Arthroscopy, elbow, surgical; with removal of loose body or foreign body

1–10 of 14

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Provider Actions and Requirements

Prior Authorization

Prior Authorization and Documentation Required

Prior authorization determinations for elbow surgical procedures are based on InterQual criteria. Providers should obtain any required authorization before scheduling services.

InterQual CP: Procedures referenced for elbow surgery (diagnostic arthroscopy, surgical arthroscopy, joint replacement, removal/revision arthroplasty) may be used to determine medical necessity.
Reference the member-specific benefit plan document and applicable federal/state mandates; the member-specific plan governs in case of conflict.
Medical records may be requested to demonstrate that the member meets clinical criteria and must be provided promptly when requested.
Submission of medical records does not guarantee coverage; inadequate or missing documentation may result in denial of the request.

Documentation Required

Medical Records and Plan Terms

Benefit coverage is determined by the member-specific benefit plan document and applicable laws. This policy is informational and does not replace the member's plan terms.

Check the member-specific benefit plan document before making coverage decisions.
In the event of a conflict between this policy and the member-specific plan, the member-specific plan controls.

Denial Risk

Documentation Impacts Coverage

Lack of adequate documentation to demonstrate that the member meets InterQual or plan-specific clinical criteria may result in denial of coverage. Provide complete and timely records to avoid delays or denials.

Provide operative notes, imaging, prior conservative treatment records, and any clinical assessments referenced by InterQual when requested.
Ensure documentation clearly supports the specific InterQual criteria being met for the requested procedure.

Background

Surgical procedures of the elbow include both diagnostic and therapeutic arthroscopic procedures and elbow arthroplasty (including total elbow replacement and revisions). Coverage determinations for these procedures rely on established clinical criteria; services are covered when the member meets the InterQual clinical criteria listed for the applicable procedure type. Refer to InterQual for the specific clinical requirements that define medical necessity for diagnostic arthroscopy, surgical arthroscopy, joint replacement, and removal or revision of arthroplasty.

Definitions

inv-09: Arthroplasty, elbow — Joint replacement procedures of the elbow including distal humeral and proximal ulnar prosthetic replacement, radial head arthroplasty, a...

TermArthroplasty, elbow

DefinitionJoint replacement procedures of the elbow including distal humeral and proximal ulnar prosthetic replacement, radial head arthroplasty, and revisions as described by specific CPT codes.

Representative CPT codes24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371

Typical procedures includedTotal elbow replacement, radial head arthroplasty, revision of components, and procedures with implant or graft as indicated by CPT descriptors.

inv-10: Arthroscopy, elbow — Diagnostic and surgical arthroscopic procedures of the elbow including synovectomy, debridement, and removal of loose bodies as described...

TermArthroscopy, elbow

DefinitionDiagnostic and surgical arthroscopic procedures of the elbow including synovectomy, debridement, and removal of loose bodies as described by specific CPT codes.

Representative CPT codes29830, 29834, 29835, 29836, 29837, 29838

Typical procedures includedDiagnostic arthroscopy (with or without synovial biopsy), removal of loose bodies, partial or complete synovectomy, limited or extensive debridement.