RetiredUnitedHealthcarePolicy CS033LA.Q

Surgery Elbow La Cs

UnitedHealthcare medical policy governing surgical procedures of the elbow for members in Louisiana; references InterQual procedural criteria for medical necessity (arthroscopy, arthroplasty, revision). The policy was retired effective April 1, 2026 and applied May 1, 2025 through March 31, 2026.

Policy Summary

PayerUnitedHealthcare

PolicySurgery Elbow La Cs

Policy CodePolicy CS033LA.Q

Change TypeRetired

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionProviders must document that the member meets the applicable InterQual CP: Procedures criteria for the specific elbow surgery when seeking coverage.

SourceLink

POLICY UPDATE CHANGES

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

05/01/2025 routine review with no change to coverage guidelines.

4InterQual procedure categories referenced

14CPT codes listed

1State-specific policy (Louisiana)

Coverage Summary

Scope: UnitedHealthcare medical policy governing surgical procedures of the elbow for members in Louisiana; references InterQual procedural criteria for medical necessity for arthroscopy, arthroplasty, and revision procedures. Effective date: 2025-05-01. Retired: 2026-04-01 (policy status: RETIRED).

Overview: Surgery of the elbow is recognized as proven and medically necessary in certain circumstances, but specific medical necessity determinations for the listed elbow procedures are delegated to InterQual CP: Procedures. The policy applied to Louisiana members from May 1, 2025 through March 31, 2026 and was retired with Louisiana plan membership disenrolled on April 1, 2026.

Medical Necessity Criteria (delegated to InterQual)

Medical Necessity Criteria (delegated to InterQual CP: Procedures)

Surgery of the elbow is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures for the listed procedures.

ALL of the following

ALL of the following
- Procedures covered when InterQual criteria are met
  - Arthroscopy, Diagnostic, +/- Synovial Biopsy, Elbow (InterQual criteria must be met)
  - Arthroscopy, Surgical, Elbow (InterQual criteria must be met)
  - Joint Replacement, Elbow (Arthroplasty) (InterQual criteria must be met)
  - Removal or Revision, Arthroplasty, Elbow (InterQual criteria must be met)
Policy applies only to Louisiana members

ref

title

Coding

Referenced CPT codes for elbow arthroplasty (for reference only)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

Provider Actions

Documentation Required

Use InterQual criteria to support medical necessity

Providers must document that the member meets the applicable InterQual CP: Procedures criteria for the specific elbow surgery (arthroscopy, arthroplasty, or revision) when requesting coverage or prior authorization.

Documentation Required

State applicability

This medical policy applies only to the state of Louisiana. Verify state and contractual requirements as federal/state/contractual terms may govern coverage.

Billing Rule

Codes listed are for reference only

The CPT codes listed are provided for reference purposes only and do not guarantee coverage or reimbursement; benefit coverage is determined by federal, state, or contractual requirements.

29830
29834
29835
29836
29837
29838
24360
24361
24362
24363
24365
24366
24370
24371

Background

This UnitedHealthcare medical policy provides guidance on coverage for elbow surgical procedures for Louisiana members and defers specific medical necessity determinations to InterQual CP: Procedures (InterQual criteria must be met for arthroscopy, diagnostic +/- synovial biopsy; arthroscopy, surgical; joint replacement/arthroplasty; and removal or revision of elbow arthroplasty).

Surgeries of the elbow are procedures and therefore are not regulated by the FDA; however, devices and instruments used during the surgery may require FDA approval.

InterQual CP: Procedures is defined as: a third-party clinical criteria set used by UnitedHealthcare to determine medical necessity for procedures.

Revision History

2026-04-01retiredLatest

Policy status changed to retired effective 04/01/2026. Retired policy; Louisiana plan membership disenrolled on Apr. 1, 2026.

2025-05-01archived

Archived previous policy version CS033LA.P following 05/01/2025 routine review with no change to coverage guidelines.