CurrentUnitedHealthcarePolicy CS109NE.Y

Surgery of the Shoulder (for Nebraska Only)

State-specific UnitedHealthcare medical policy (Nebraska) describing coverage rationale and applicable coding for shoulder surgeries, referencing InterQual clinical criteria for medical necessity; includes an explicit noncoverage statement for subacromial balloon spacers (SABS) as unproven.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Shoulder (for Nebraska Only)

Policy CodePolicy CS109NE.Y

Change TypeState-specific creation; criteria references revised; evidence/update

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders and reviewers must reference InterQual CP: Procedures modules listed in the policy to determine medical necessity for shoulder procedures; medical records documentation may be required to demonstrate criteria are met.

SourceLink

POLICY UPDATE CHANGES

Created state-specific policy version for the state of Nebraska.

Revised language pertaining to medical necessity clinical coverage criteria to add and remove references to specific InterQual modules.

Updated Clinical Evidence and References sections; archived previous policy version CS109.X.

1State-specific policy (Nebraska)

5Referenced InterQual procedure modules

1Explicit not-covered intervention (SABS)