UnitedHealthcare Omnibus Codes Coverage Update

Coverage Conclusions and Routing

Coverage conclusions and routing logic

Conclusions provided per code in this section:

Codes concluded Not reasonable and necessary unless otherwise noted: Many listed codes are concluded 'Not reasonable and necessary; refer to the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes.'

Applies to multiple codes across chunks 1-19

Codes with CMS NCD = Yes: For codes where CMS NCD Coverage Criteria = Yes, refer to the named NCD for coverage guidelines (examples: 0338T/0339T -> NCD for Renal Denervation (20.40); 0408T-0418T -> NCD for Cardiac Contractility Modulation (20.39)).

Follow NCD requirements for those codes

When CMS LCD/LCA exists: If a CMS LCD/LCA exists for a listed code (e.g., WPS L35490 for certain intracardiac ischemia monitoring system codes; Noridian L34149 for 94011–94013; Palmetto L39385 for 0640T), follow that LCD/LCA for state-specific coverage guidance; otherwise refer to UnitedHealthcare Omnibus Commercial policy for guidance.

Follow LCD/LCA when present

Coverage conclusions and routing

UnitedHealthcare conclusions for listed codes in this section

Refer to NCD: For codes with 'CMS NCD Coverage Criteria = Yes', UnitedHealthcare directs providers to refer to the relevant CMS NCD for coverage determination (examples: CCM NCD 20.39 for CPT codes 0408T–0418T and K1030; ICD NCD 20.4 for substernal ICD codes 0571T–0580T and 0614T; RDN NCD 20.40 for 0338T/0339T).

See cited NCDs for criteria

Refer to LCD/LCA or local contractor: For codes with an indicated LCD/LCA (for example WPS L35490 for select intracardiac ischemia monitoring system codes or Noridian L34149 for 94011–94013), UnitedHealthcare refers providers to those local coverage articles for state/territory-specific guidance.

Follow local contractor guidance when present

Not reasonable and necessary: Many codes in this section are concluded 'Not reasonable and necessary' by UnitedHealthcare and the provider is instructed to refer to the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes for details and any prior authorization requirements.

Referral to Omnibus Codes policy

Not reasonable and necessary (default)

UnitedHealthcare conclusions for listed codes in this segment

Primary stance: Listed codes are concluded to be 'Not reasonable and necessary' unless otherwise directed by a referenced LCD/LCA or the UnitedHealthcare Omnibus Codes policy.

Refer to Omnibus Codes policy for any exceptions or prior authorization rules

Referral to NCDs for specific device/procedure coverage

When applicable internal guidance was replaced:

NCD referral requirement: Replace prior internal coverage language and refer to the applicable National Coverage Determination (NCD) for CCM (20.39), ICDs (20.4), and RDN (20.40).

Operational instruction to follow NCDs

When this policy lists a code as Not reasonable and necessary, UnitedHealthcare Medicare Advantage has concluded the service is not covered in the absence of an applicable Medicare NCD/LCD/LCA or a specific UnitedHealthcare Medicare Advantage policy. Providers must first search the Medicare Coverage Database for any National Coverage Determination (NCD), Local Coverage Determination (LCD) or Local Coverage Article (LCA); if none exists, refer to the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes for the insurer’s documentation, prior authorization, and coverage rules. Services concluded Not reasonable and necessary will be denied per the stated conclusions unless a separate applicable coverage policy indicates otherwise.

This document explicitly designates numerous codes as Not reasonable and necessary and directs providers to the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes for handling those services (examples include laboratory and algorithmic tests such as 0163U, and multianalyte reporting codes such as 81599). When a code here is labeled Not reasonable and necessary, follow the Omnibus Codes policy for any exceptions, required documentation, or prior authorization processes.

Where a specific CMS LCD/LCA or other local contractor guidance exists for a listed code, follow that LCD/LCA for state- or territory-specific coverage guidance rather than the default Not reasonable and necessary stance. Examples in this policy that reference LCD/LCA guidance include codes such as 0859T, 19294, 43206, 43252, and 94011–94013—providers should use the noted LCD/LCA when determining coverage and documentation requirements.

Operational changes in this revision replace previous internal coverage language for certain device-related codes with explicit instruction to follow the named CMS National Coverage Determination (NCD) where applicable. For example, Cardiac Contractility Modulation (CCM) codes and related supply code K1030 are now governed by NCD 20.39, and Implantable Cardioverter-Defibrillator (ICD) device codes are referred to NCD 20.4. UnitedHealthcare directs providers to the referenced NCDs in lieu of prior internal policy text for coverage determinations.

Examples of codes in this policy explicitly concluded to be Not reasonable and necessary (excerpted) include, but are not limited to: 0061U, 0163U, 0174T, 0175T, 0207T, 0208T–0212T, 0234T–0237T, 0247U, and several device interrogation and implant codes; when these codes are listed as Not reasonable and necessary, providers should refer to the UnitedHealthcare Omnibus Codes policy for further handling.

Additional examples of codes concluded Not reasonable and necessary include (excerpt): 0444T, 0445T, 0472T, 0473T, 0485T–0486T, 0506T–0507T, multiple sinus tarsi and intracardiac monitoring codes in the 0510T–0529T range, 3‑D printing codes 0559T–0562T, and procedure codes in the 0581T–0618T range. These listings are illustrative; consult the policy table for the complete list and reference the Omnibus Codes policy for exceptions.

Multiple specific procedure and supply codes are stated in this section as Not reasonable and necessary and are therefore managed per the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes. Examples include donor hysterectomy and uterine transplant preparation codes (0664T–0670T), therapeutic ultrafiltration (0692T), various imaging and endomicroscopy codes (43206, 43252, 88375), unlisted and miscellaneous supply codes (17999, L8699, C1839), and certain drug assay and DME miscellaneous codes (80145, 80230, 80280, E1399). Providers should follow Omnibus Codes policy for documentation, prior authorization, and coverage exceptions.

Coverage for certain codes depends on the referenced CMS National Coverage Determination or the member’s specific benefit documents. Where this policy indicates a code is governed by a named NCD (for example, renal denervation codes 0338T/0339T referred to NCD 20.40, CCM codes 0408T–0418T referred to NCD 20.39, and substernal ICD/ICD-related codes referred to NCD 20.4), follow the NCD criteria for coverage determinations. Absent an applicable NCD/LCD/LCA, the Omnibus Codes policy and the member’s plan benefits apply.

Codes and Coding Guidance

Mixed CPT/HCPCS codes with UnitedHealthcare conclusions (neutral)mixed

0061U	Transcutaneous measurement of five biomarkers using SFDI — Conclusion: Not reasonable and necessary; refer to UnitedHealthcare Commercial Medical Policy titled Omnibus Codes.
0075T	Transcatheter placement of extracranial vertebral artery stent(s) — Conclusion: For coverage guidelines where no LCDs/LCAs exist, refer to UnitedHealthcare Commercial Medical Policy titled Omnibus Codes.
0163U	Oncology (colorectal) screening ELISA with algorithm — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0174T	Computer-aided detection (CAD) with further physician review, concurrent — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0175T	Computer-aided detection (CAD) remote from primary interpretation — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0207T	Evacuation of meibomian glands, automated, unilateral — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0208T	Pure tone audiometry (threshold), automated; air only — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0209T	Pure tone audiometry (threshold), automated; air and bone — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0210T	Speech audiometry threshold, automated — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0211T	Speech audiometry threshold, automated; with speech recognition — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

1–10 of 16

1/2

Device interrogation/programming codes (neutral)CPT

0272T	Interrogation device evaluation (in person), carotid sinus baroreflex activation system — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0273T	Interrogation device evaluation with programming (Deleted 12/31/2025 - See 93145/93146) — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

Ophthalmic/device codes (neutral)CPT

0330T	Tear film imaging with interpretation and report — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0444T	Initial placement of drug-eluting ocular insert — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0445T	Subsequent placement of drug-eluting ocular insert — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0472T	Device evaluation, interrogation, and initial programming of intraocular retinal electrode array — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

Assorted device and imaging codes (neutral)mixed

0485T	OCT of middle ear, unilateral — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0486T	OCT of middle ear, bilateral — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0506T	Macular pigment optical density measurement — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0507T	Near-infrared dual imaging of meibomian glands — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0510T	Removal of sinus tarsi implant — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0511T	Removal and reinsertion of sinus tarsi implant — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0515T	Insertion of wireless cardiac stimulator for left ventricular pacing, complete system — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

Intracardiac ischemia monitoring system codes (neutral)CPT

0525T	Insertion or replacement of intracardiac ischemia monitoring system, complete system — For coverage guidelines where no LCDs/LCAs exist, refer to UnitedHealthcare Commercial Medical Policy titled Omnibus Codes (WPS* references noted).
0526T	Insertion or replacement; electrode only — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (WPS* L35490).
0527T	Insertion or replacement; implantable monitor only — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (WPS* L35490).
0528T	Programming device evaluation of intracardiac ischemia monitoring system — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (WPS* L35490).
0529T	Interrogation device evaluation with analysis, review, and report — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (WPS* L35490).

3D printing and eyelid/meibomian procedures (neutral)CPT

0559T	Anatomic model 3D-printed; first component — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0560T	Anatomic model 3D-printed; additional component — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0561T	Anatomic guide 3D-printed; first guide — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0562T	Additional anatomic guide — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0563T	Evacuation of meibomian glands using wearable open-eye devices, bilateral — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

Substernal ICD system codes (covered; refer to NCD 20.4)CPTCovered

0571T	Insertion or replacement of ICD system with substernal electrode(s) — Refer to NCD for Implantable Cardioverter Defibrillators (ICDs) (20.4).
0572T	Insertion of substernal implantable defibrillator electrode — Refer to NCD 20.4.
0573T	Removal of substernal implantable defibrillator electrode — Refer to NCD 20.4.
0574T	Repositioning of previously implanted substernal electrode — Refer to NCD 20.4.
0575T	Programming device evaluation (in person) of ICD system with substernal electrode — Refer to NCD 20.4.
0576T	Interrogation device evaluation (in person) of ICD system with substernal electrode — Refer to NCD 20.4.
0577T	Electrophysiologic evaluation of ICD system with substernal electrode — Refer to NCD 20.4.
0578T	Interrogation device evaluation(s) (remote), up to 90 days, substernal lead ICD system — Refer to NCD 20.4; remote interrogation period up to 90 days.
0579T	Interrogation device evaluation(s) (remote), up to 90 days; remote data acquisition/transmission — Refer to NCD 20.4.
0580T	Removal of substernal implantable defibrillator pulse generator only — Refer to NCD 20.4.

1–10 of 11

1/2

Mixed procedural and monitoring codes (neutral)mixed

0581T	Ablation, malignant breast tumor(s), percutaneous, cryotherapy — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0583T	Tympanostomy using automated tube delivery system with iontophoresis local anesthesia — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0594T	Osteotomy, humerus, with insertion of externally controlled intramedullary lengthening device — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0600T	Ablation, irreversible electroporation; tumors other than liver/prostate, percutaneous — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0601T	Ablation, irreversible electroporation; open — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0607T	Remote monitoring of external continuous pulmonary fluid monitoring system; setup and education — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0608T	Remote monitoring of external continuous pulmonary fluid monitoring system; analysis and report transmission — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

Transplantation, endoscopy, and other procedural codes (neutral)mixed

0664T	Donor hysterectomy, open, from cadaver donor — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0665T	Donor hysterectomy, open, from living donor — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0666T	Donor hysterectomy, laparoscopic or robotic, from living donor — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0667T	Recipient uterus allograft transplantation — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0668T	Backbench preparation of uterine allograft prior to transplantation — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0669T	Backbench reconstruction; venous anastomosis — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0670T	Backbench reconstruction; arterial anastomosis — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.
0692T	Therapeutic ultrafiltration — Conclusion: Not reasonable and necessary; refer to Omnibus Codes.

Codes listed with UnitedHealthcare conclusions (not_covered)mixedNot Covered

17999	Unlisted procedure, skin/mucous membrane/subcutaneous tissue — Not reasonable and necessary; refer to Omnibus Codes.
19105	Ablation, cryosurgical, of fibroadenoma — Not reasonable and necessary; refer to Omnibus Codes.
19294	Preparation of tumor cavity with placement of IORT applicator concurrent with partial mastectomy — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (Palmetto L37779 noted).
31634	Bronchoscopy with balloon occlusion assessment of air leak — Not reasonable and necessary; refer to Omnibus Codes.
43206	Esophagoscopy with optical endomicroscopy — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (Novitas/Palmetto references noted).
43252	EGD with optical endomicroscopy — For coverage guidelines where no LCDs/LCAs exist, refer to Omnibus Codes (Novitas/Palmetto references noted).
47384	Ablation, irreversible electroporation, liver — Not reasonable and necessary; refer to Omnibus Codes (Effective 01/01/2026).
53451	Periurethral adjustable balloon continence device insertion, bilateral — Not reasonable and necessary; refer to Omnibus Codes.
53452	Periurethral adjustable balloon continence device insertion, unilateral — Not reasonable and necessary; refer to Omnibus Codes.
53453	Removal of periurethral adjustable balloon continence device — Not reasonable and necessary; refer to Omnibus Codes.

1–10 of 11

1/2

Cardiac Contractility Modulation (CCM) codes (refer to NCD 20.39)CPT

0408T	Insertion/replacement of permanent CCM system, complete — Refer to NCD 20.39 CCM for HF.
0409T	Insertion/replacement of CCM system, pulse generator only — Refer to NCD 20.39.
0410T	Insertion/replacement of CCM system, atrial electrode only — Refer to NCD 20.39.
0411T	Insertion/replacement of CCM system, includes contractility evaluation — Refer to NCD 20.39.
0412T	Removal of CCM system; pulse generator only — Refer to NCD 20.39.
0413T	Removal of CCM system; transvenous electrode — Refer to NCD 20.39.
0414T	Removal and replacement of CCM pulse generator only — Refer to NCD 20.39.
0415T	Repositioning of CCM transvenous electrode — Refer to NCD 20.39.
0416T	Relocation of skin pocket for CCM pulse generator — Refer to NCD 20.39.
0417T	Programming device evaluation (in person) for CCM — Refer to NCD 20.39.

1–10 of 12

1/2

ICD-related and substernal ICD codes (neutral/see NCD 20.4)CPT

0571T	Insertion/replacement of ICD system with substernal electrode(s) — Refer to NCD 20.4.
0572T	Insertion of substernal defibrillator electrode — Refer to NCD 20.4.
0573T	Removal of substernal defibrillator electrode — Refer to NCD 20.4.
0574T	Repositioning of previously implanted substernal electrode — Refer to NCD 20.4.
0575T	Programming device evaluation (in person) for substernal ICD — Refer to NCD 20.4.
0576T	Interrogation device evaluation (in person) for substernal ICD — Refer to NCD 20.4.
0577T	Electrophysiologic evaluation of substernal ICD system — Refer to NCD 20.4.
0578T	Remote interrogation(s) up to 90 days for substernal lead ICD system — Refer to NCD 20.4.
0579T	Remote data acquisition and technician review for substernal ICD — Refer to NCD 20.4.
0580T	Removal of substernal defibrillator pulse generator only — Refer to NCD 20.4.

1–10 of 11

1/2

Renal Denervation (RDN) codes (refer to NCD 20.40)CPT

0338T	Transcatheter renal sympathetic denervation, percutaneous approach — CMS NCD = Yes; refer to NCD 20.40 RDN for Uncontrolled Hypertension.
0339T	Transcatheter renal sympathetic denervation, percutaneous approach — CMS NCD = Yes; refer to NCD 20.40.

Prior Authorization

Provider Action / Billing Rule

Provider Action: When submitting claims for codes listed in this section, verify applicable Medicare NCD/LCD/LCA before billing. For codes where the CMS NCD = Yes, follow the referenced NCD (e.g., NCD 20.39 for CCM codes; NCD 20.4 for ICDs; NCD 20.40 for RDN). For codes with CMS LCD/LCA references, follow the listed LCD/LCA for state/territory-specific coverage. If no Medicare guidance applies, use the UnitedHealthcare Commercial Medical Policy titled "Omnibus Codes" for coverage determinations. Maintain clinical documentation demonstrating medical necessity and adherence to NCD/LCD criteria when applicable to avoid claim denials.

Verify Medicare NCD/LCD/LCA prior to billing for listed codes.
Follow referenced NCDs when CMS NCD = Yes (examples: CCM NCD 20.39; ICD NCD 20.4; RDN NCD 20.40).
If no Medicare guidance, refer to UnitedHealthcare Commercial Medical Policy titled "Omnibus Codes."
Retain documentation supporting medical necessity and NCD/LCD adherence to reduce denial risk.

Provider Requirements and Operational Guidance

Prior Authorization

NCD-referred ICD and substernal lead device codes

Many substernal ICD and related device procedure codes in this policy (e.g., 0571T–0579T, 0580T, 0614T) are designated CMS NCD Coverage Criteria = Yes; providers must refer to the NCD for Implantable Cardioverter Defibrillators (ICDs) when determining coverage and prior authorization needs.

Follow the ICD NCD (20.4) for coverage determinations for substernal lead ICD procedure and interrogation codes.

Prior Authorization

Refer to Omnibus Codes / LCDs for prior authorization

Codes concluded 'Not reasonable and necessary' in this document often require referral to the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes or to an applicable LCD/LCA for prior authorization and coverage details.

If a CMS LCD/LCA exists for the code (for example, intracardiac ischemia monitoring codes with WPS L35490), follow that LCD/LCA for coverage and prior authorization instructions; otherwise refer to the Omnibus Codes policy.

Prior Authorization

Covered Indications (Documented)

None in this part — specific lab tests are listed but concluded Not reasonable and necessary unless covered by an applicable NCD/LCD or specific UHC policy

None in this part — specific lab tests are listed but concluded Not reasonable and necessary unless covered by an applicable NCD/LCD or specific UHC policy.

Laboratory tests default stance: Specific laboratory or biomarker tests named in this section (for example CPT/PLA codes 0061U, 0163U, 0247U) are concluded Not reasonable and necessary in this policy excerpt unless an applicable NCD, LCD/LCA, or a specific UnitedHealthcare policy provides coverage.

Providers should consult Medicare Coverage Database and UHC policies before billing

81599 (unlisted multianalyte assay when used to report PreTrm) listed as not reasonable and necessary; refer to Omnibus Codes policy for any covered indications

81599 (unlisted multianalyte assay when used to report PreTrm) is listed as not reasonable and necessary; refer to Omnibus Codes policy for any covered indications.

81599 conclusion: CPT 81599 (unlisted multianalyte assay with algorithmic analysis, when used to report PreTrm) is concluded Not reasonable and necessary; providers should refer to the UnitedHealthcare Commercial Medical Policy titled Omnibus Codes for any potential covered indications or prior authorization requirements.

Services and Codes Not Covered

Specific laboratory or biomarker tests listed in this policy (for example, 0061U spatial frequency domain imaging biomarkers, 0163U colorectal ELISA panel, and 0247U IBP4/SHBG preterm birth panel) are concluded to be Not reasonable and necessary in this excerpt unless an applicable CMS NCD/LCD or a separate UnitedHealthcare policy provides coverage. For 81599 (unlisted multianalyte assay used to report PreTrm), the policy likewise concludes the code is Not reasonable and necessary and directs providers to the Omnibus Codes policy for any covered indications.

This section lists procedures and tests concluded Not reasonable and necessary, including optical coherence tomography (OCT) of the middle ear (0485T/0486T), macular pigment measurement (0506T), near-infrared meibomian gland imaging (0507T), and examples of 3‑D printing anatomic models and guides (0559T–0562T). When these services are billed, providers should expect denials unless an applicable NCD/LCD/LCA or the Omnibus Codes policy indicates otherwise.

Drug assay codes and related laboratory reporting codes are concluded Not reasonable and necessary in this segment. Examples include therapeutic drug monitoring assay codes 80145 (adalimumab), 80230 (infliximab), and 80280 (vedolizumab), and the unlisted multianalyte assay code 81599 (when used to report PreTrm). Providers should follow the Omnibus Codes policy for any required documentation or exceptions and complete the required Medicare and UnitedHealthcare policy searches prior to billing.

This policy provides a cross-reference to MolDX molecular diagnostic test policies for additional molecular/multi‑omics and proteomics testing guidance. While the excerpt does not exclude specific MolDX-listed tests in full, it lists MolDX policy identifiers (for example, L36021, L35160, L36256, L35025, L36807) and related billing/coding cross-reference documents that providers may consult for molecular diagnostic coverage and coding considerations.

Definitions and Key Terms

Omnibus codes

Definition: Omnibus codesCodes that are new, miscellaneous, proprietary, or not specifically addressed by existing Medicare coverage determinations and are grouped here for coverage guidance

Use when no Medicare guidance existsIf no NCD/LCD/LCA is found in the Medicare Coverage Database and no specific UHC MA policy exists, treat the code as an omnibus code and follow the UnitedHealthcare Omnibus Codes policy

Includes PLA/Category III/CPT temporary codesPolicy compiles miscellaneous/new/proprietary procedure and laboratory codes including PLA/Category III/CPT temporary codes

CMS NCD

CMS National Coverage Determination (NCD) referencedSeveral device-related codes are explicitly referred to named CMS NCDs for coverage guidance (examples: 0338T/0339T -> RDN NCD 20.40; 0408T–0418T -> CCM NCD 20.39; 0571T–0580T -> ICD NCD 20.4)

When CMS NCD = Yes

Ordering and Prior Authorization Requirements

Note

ORDERING: Search Medicare Coverage Database and UHC MA policies

Providers must search the Medicare Coverage Database and UnitedHealthcare Medicare Advantage policies to determine coverage for an order; no additional ordering restrictions are specified in this excerpt.

If no Medicare NCD/LCD/LCA or UHC MA policy is found, document the searches and refer to the Omnibus Codes policy per the member’s benefit.

Note

ORDERING: No provider-specific ordering requirements specified

This segment does not specify any ordering provider requirements; when applicable follow the UnitedHealthcare Omnibus Codes policy or any relevant LCD/LCA for ordering rules.

Adhere to any ordering provider rules specified in the LCD/LCA or Omnibus policy for the service.
Follow member-specific benefit requirements when they differ.

Note

Background and Scope

Background: This UnitedHealthcare Medicare Advantage policy compiles miscellaneous, new, or proprietary procedure and laboratory codes—including PLA/Category III/CPT temporary codes—and provides guidance for coverage when no Medicare NCD/LCD/LCA or specific UHC MA policy exists. Several listed items are laboratory tests or proprietary algorithmic assays; many codes in this compilation are concluded Not reasonable and necessary absent an applicable Medicare or UnitedHealthcare coverage policy.

Frequency Limits

Frequency limits (placeholder)

No frequency limits specified in this excerptThis policy segment does not list specific frequency limits for tests or procedures; providers should follow applicable NCD/LCD/LCA or UnitedHealthcare Omnibus Codes policy when frequency limits are relevant

Follow referenced guidance for limitsWhen an NCD or LCD/LCA specifies frequency rules, follow those source documents for allowable intervals

Record retentionProviders are expected to retain documentation to support medical necessity and frequency when requested

Policy Change Log

2026-02-01Revision - policy updateLatest

Replaced prior internal coverage language for Cardiac Contractility Modulation (CPT 0408T–0418T, K1030), Implantable Cardioverter-Defibrillators (CPT 0571T–0580T, 0614T), and Renal Denervation (CPT 0338T/0339T/0388T) with instructions to refer to the applicable CMS National Coverage Determinations (NCD 20.39 for CCM, NCD 20.4 for ICDs, and NCD 20.40 for RDN).