CurrentUnitedHealthcarePolicy CS343PA.G

Surgery Hand Wrist Pa Cs

State-specific UnitedHealthcare medical policy (Pennsylvania only) defining that hand and wrist surgeries are medically necessary in certain circumstances and deferring to InterQual procedural criteria for clinical coverage determinations; includes an applicable CPT code list and references Pennsylvania Code Title 55, Chapter 1101.

Policy Summary

PayerUnitedHealthcare

PolicySurgery Hand Wrist Pa Cs

Policy CodePolicy CS343PA.G

Change TypeRoutine review (no change)

Effective DateJul 1, 2025

Next Review Date

Key ActionProviders must document clinical indications and supporting information consistent with the InterQual CP: Procedures for the specific hand/wrist surgery to demonstrate medical necessity; the policy defers to InterQual criteria linked in the policy.

SourceLink

POLICY UPDATE CHANGES

07/01/2025 routine review; no change to coverage guidelines; archived previous policy version CS343PA.F

16Procedure Codes Listed

PennsylvaniaGeographic Scope

InterQualExternal Criteria Used

Coverage Summary

This Pennsylvania-specific UnitedHealthcare medical policy (Policy Number: CS343PA.G) covers surgical procedures of the hand and wrist and states that such surgeries are covered with criteria when the referenced InterQual procedural criteria are met. The policy is effective 07/01/2025 and was last reviewed on 07/01/2025. Policy history notes a routine review with no change to coverage guidelines and archival of the previous version.

Medical Necessity Criteria (InterQual referenced)

Medical Necessity Criteria (referenced)

Covered when ALL of the following InterQual procedural criteria for the listed procedures are met:

ALL of the following

Procedure examples: Procedure is one of the InterQual CP: Procedures listed (examples include Arthroplasty CMC Thumb; Arthroplasty MCP Digits; Arthroplasty PIP Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Diagnostic Arthroscopy +/- Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision, Arthroplasty, Wrist)
Referenced InterQual CP: Procedures list
InterQual criteria requirement: Clinical indication meets the specific InterQual criteria for the selected procedure (refer to InterQual CP: Procedures link)
See InterQual CP: Procedures
Pennsylvania applicability and PARP: Policy applies only to members in the state of Pennsylvania; requests not meeting PARP criteria will be evaluated case-by-case per Pennsylvania Exceptions, PA Code Title 55, Chapter 1101
State-specific applicability

Applicable CPT / Procedure Codes

Applicable CPT / Procedure Codes (reference list)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 & Documentation Requirements

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must document clinical indications and supporting information consistent with the InterQual CP: Procedures for the specific hand/wrist surgery to demonstrate medical necessity; the policy defers to InterQual criteria linked in the policy.

Documentation Required

State-specific applicability and exceptions

Ensure member is in Pennsylvania and follow PARP and PA Code Title 55, Chapter 1101; requests not meeting PARP criteria will be evaluated case-by-case.

Applies PARP / PA Code Title 55, Chapter 1101

Background

This policy applies only to members in the state of Pennsylvania and covers surgical procedures of the hand and wrist when medically necessary per the policy criteria. The policy specifies that hand and wrist surgeries are procedures (not regulated by the FDA), although devices and instruments used during surgery may require FDA approval.

Medical necessity determinations defer to the InterQual CP: Procedures listed in the policy (examples include Arthroplasty CMC Thumb; Arthroplasty MCP Digits; Arthroplasty PIP Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Diagnostic Arthroscopy +/- Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision, Arthroplasty, Wrist).

PARP: Pennsylvania Exceptions referenced in PA Code Title 55, Chapter 1101 (policy applies to Pennsylvania only).