CurrentUnitedHealthcarePolicy CS033PA.S

Surgery Elbow Pa Cs

Defines UnitedHealthcare Pennsylvania-specific medical policy for surgical procedures of the elbow, referencing InterQual CP procedural criteria for medical necessity and listing applicable CPT codes; documents required medical record documentation standards. Applies only to Pennsylvania.

Policy Summary

PayerUnitedHealthcare

PolicySurgery Elbow Pa Cs

Policy CodePolicy CS033PA.S

Change TypeAdded documentation clarification

Effective DateMar 1, 2026

Next Review Date

Key ActionInclude relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; ensure documentation is legible, maintained in the medical record, and available upon request.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying medical records documentation used for reviews and detailing required documentation elements supporting medical necessity.

4InterQual referenced procedure categories

13CPT codes listed

Coverage Summary

Coverage is determined by meeting the InterQual CP: Procedures criteria for the listed procedures. Surgery of the elbow is proven and medically necessary in certain circumstances when InterQual criteria are met.

Medical-Necessity Criteria (InterQual-referenced)

Medically Necessary (per InterQual CP Procedural Criteria)

Coverage is determined by meeting the InterQual CP: Procedures criteria for the listed procedures. Surgery of the elbow is proven and medically necessary in certain circumstances when InterQual criteria are met.

Medically Necessary per InterQual: Request must meet InterQual CP procedural criteria for one of the following procedures: Arthroscopy, Diagnostic +/- Synovial Biopsy, Elbow; Arthroscopy, Surgical, Elbow; Joint Replacement, Elbow; Removal or Revision, Arthroplasty, Elbow

Refer to InterQual® CP: Procedures for the detailed medical necessity criteria.

Documentation Requirements for Coverage Determination

All requests require medical record documentation that supports medical necessity:

Documentation Requirements: Relevant medical history is documented in the patient's record

Documentation Requirements: Physical examination findings are documented in the patient's record

Documentation Requirements: Results of pertinent diagnostic tests or procedures are documented

Documentation Requirements: Documentation is legible, maintained in the patient's medical record, and must be made available upon request

Documentation Requirements: Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; meeting documentation requirements does not guarantee coverage

Codes (reference lists)

Arthroplasty / Joint Replacement Elbow CPT codes (reference list)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.

Elbow Arthroscopy CPT codes (reference list)CPT

29830	Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure).
29834	Arthroscopy, elbow, surgical, with removal of loose body or foreign body.
29835	Arthroscopy, elbow, surgical; synovectomy, partial.
29836	Arthroscopy, elbow, surgical; synovectomy, complete.
29837	Arthroscopy, elbow, surgical, debridement, limited.
29838	Arthroscopy, elbow, surgical, debridement, extensive.

Provider Actions / Prior Authorization & Documentation

Documentation Required

Provide complete medical record documentation

Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures in the patient's medical record. Documentation supporting medical necessity should be legible, maintained in the medical record, and made available upon request. Note that benefit coverage is determined by federal, state, or contractual requirements and applicable laws; meeting documentation requirements does not guarantee coverage.

Relevant medical history documented in the patient's record
Physical examination findings documented in the patient's record
Results of pertinent diagnostic tests or procedures documented
Documentation is legible, maintained in the patient's medical record, and must be made available upon request

Prior Authorization

Prior authorization/coverage assessment per InterQual

Requests that do not meet the InterQual procedural criteria will be evaluated on a case-by-case basis. When submitting requests for coverage determination, reference the InterQual CP procedural criteria for the applicable elbow procedures (arthroscopy diagnostic +/- synovial biopsy, arthroscopy surgical, joint replacement, removal or revision/arthroplasty).

Background

This Pennsylvania-specific policy notes that surgery of the elbow is a procedure (and therefore not regulated by the FDA), though devices and instruments used during surgery may require FDA approval.

Benefit coverage and determinations are governed by applicable federal, state, or contractual requirements and laws; medical records documentation may be required to assess whether clinical criteria are met but does not guarantee coverage.

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation should be legible, maintained in the medical record, and made available upon request.

InterQual CP: A third-party clinical criteria tool used by UnitedHealthcare to assist in determining medical necessity for procedures.

Revision History

2026-03-01material_changeLatest

Added language clarifying medical records documentation used for reviews: Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; the patient's medical record must contain documentation fully supporting medical necessity (including relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures); documentation should be legible, maintained in the patient's medical record, and made available upon request.