Currentsierra health and lifePolicy 2026T0623L

Surgery of the Hand or Wrist

Defines UnitedHealthcare commercial and Individual Exchange coverage rationale, coding references, and use of InterQual criteria for various hand and wrist surgical procedures; applies to members covered under the payer's commercial and individual exchange plans.

Policy Summary

Payersierra health and life

PolicySurgery of the Hand or Wrist

Policy CodePolicy 2026T0623L

Change TypeTemplate Update (no material changes)

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain and document evidence that the member meets InterQual criteria and member-specific benefit plan requirements prior to authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InterQualclinical criteria source

17 listedprocedure codes

Commercialplan applicability

Individual Exchangeplan applicability

Templaterecent revision note

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Medical Necessity (InterQual guided)

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

InterQual-based medical necessity: Member meets the specific InterQual CP: Procedures criteria for the requested hand or wrist surgery (examples include: Arthroplasty, Carpometacarpal (CMC) Joint, Thumb; Arthroplasty, Metacarpophalangeal (MCP) Joint, Digits; Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision, Arthroplasty, Wrist).refer to InterQual

InterQual criteria detail not reproduced in this policy; provider must consult InterQual for the exact clinical requirements and documentation needed for authorization.

The information in this section about the U.S. Food and Drug Administration (FDA) is provided for informational purposes only. FDA approval alone is not a basis for coverage. Surgeries of the hand or wrist are clinical procedures and, as such, are not regulated by the FDA; however, devices and instruments used during these procedures may require FDA approval. Providers may consult the FDA device databases for device-specific approval status when relevant to a case.

The procedure and diagnosis codes listed in this policy are 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. Coverage for any service is determined by the member-specific benefit plan document and applicable laws and regulations.

Procedure Codes and Coding References

Procedure CPT Codes (reference)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.
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.

1–10 of 17

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Provider Actions and Authorization

Prior Authorization

Authorization guided by InterQual criteria

Prior authorization decisions are guided by InterQual criteria. Providers should obtain and document clinical evidence demonstrating that the member meets the applicable InterQual CP: Procedures criteria (for example: Arthroplasty CMC thumb, MCP joint arthroplasty, PIP joint arthroplasty, wrist arthroscopy, diagnostic wrist arthroscopy, joint replacement or removal/revision of wrist arthroplasty).

Reference the specific InterQual procedure criteria when requesting authorization
Click here to view the InterQual® criteria

Note

Providers must take action to request authorization and supply supporting documentation at the time of the request. Ensure the clinical record clearly documents diagnosis, prior treatments, functional limitation, and other information required by InterQual.

Include operative reports, imaging, office notes, and conservative treatment documentation as applicable
State the specific InterQual criteria met in the request

Documentation Required

Medical records requirement

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage. Submit relevant records with the prior authorization request or as soon as possible when requested by the plan.

Examples: diagnostic imaging, physical exam findings, prior conservative care records, specialist consultation notes

Denial Risk

Documentation affects coverage determination

Benefit coverage is determined by the member-specific benefit plan document and applicable laws. Lack of required documentation or failure to meet InterQual criteria may result in denial or non-coverage of the requested service.

Inclusion of codes in policy does not guarantee payment; other policies and guidelines may apply
Coverage subject to member's plan benefits and applicable law

Background

Hand and wrist surgical procedures encompass a range of operative interventions including joint-preserving and joint-replacing operations. Examples include arthroplasty of the thumb carpometacarpal (CMC), metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints; wrist arthroscopy for diagnostic or therapeutic purposes; partial or total wrist joint replacement; and removal or revision of prior arthroplasty implants. Clinical coverage determinations for these procedures are supported by standardized InterQual clinical criteria, which define the specific medical necessity requirements for each request.

Definitions

InterQual criteria — definition and scope

DefinitionInterQual criteria — third-party evidence-based clinical criteria used to evaluate medical necessity for listed hand and wrist surgical procedures.

ScopeApplies to InterQual CP: Procedures for hand and wrist surgeries including CMC thumb arthroplasty; MCP and PIP joint arthroplasty; wrist arthroscopy (diagnostic and therapeutic); wrist joint replacement; and removal or revision of wrist arthroplasty.

Where to find detailsClinical detail and specific medical necessity requirements are contained in the referenced InterQual CP: Procedures; providers must consult InterQual for exact criteria.

Role in coverage determinationsInterQual criteria are used to determine medical necessity for the listed procedures and guide authorization decisions.

Examples of referenced InterQual topicsArthroplasty, Carpometacarpal (CMC) Joint, Thumb; Arthroplasty, Metacarpophalangeal (MCP) Joint, Digits; Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision, Arthroplasty, Wrist.