CurrentUnitedHealthcarePolicy MMP068.09

Orthopedic Procedures, Devices, and Products

UnitedHealthcare Medicare Advantage policy MMP068.09 provides Medicare-focused guidance and code listings for select orthopedic procedures/devices/products (computer-assisted surgical navigation, extracorporeal shock wave therapy, and manipulation under anesthesia of spine/pelvis), references applicable LCDs/LCAs and MAC jurisdictions, and describes use of internal coverage criteria when Medicare guidance is absent.

Policy Summary

PayerUnitedHealthcare

PolicyOrthopedic Procedures, Devices, and Products

Policy CodePolicy MMP068.09

Change TypeAdded code

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders are expected to retain or have access to appropriate documentation to support coverage when requested; benefit coverage depends on member-specific plan and applicable laws.

POLICY UPDATE CHANGES

Added CPT code 27599 to Applicable Codes.

3Primary procedure groups referenced

1CPT codes added in this revision

Coverage Summary

Applicable Codes

Computer-Assisted Surgical Navigation - referenced procedure codesCPT

0054T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)
20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)
27599	Unlisted procedure, femur or knee (e.g., kinetic balance sensor)

Extracorporeal Shock Wave Therapy (ESWT) - referenced procedure codesmixed

0101T	Extracorporeal shock wave involving musculoskeletal system, not otherwise specified
0102T	Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle
28890	Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia

Manipulation Under Anesthesia (MUA) for Spine and Pelvis - referenced procedure codeCPT

22505

Manipulation of spine requiring anesthesia, any region

This revision added CPT code 27599 to the Applicable Codes list. Listing of a code in this policy does not imply the service is covered or will be reimbursed; providers must follow CPT/CMS coding guidelines and the member benefit plan for payment determinations.

Provider Actions & Billing Considerations

Documentation Required

Retain documentation for coverage decisions

Providers are expected to retain or have access to appropriate documentation to support coverage when requested; benefit coverage depends on member-specific plan and applicable laws.

Billing Rule

Codes listed for reference do not guarantee coverage or payment

The listing of a code in this policy is for reference only and does not imply the service is covered or will be reimbursed. Providers must follow CPT/CMS coding guidelines and the member specific benefit plan document for payment determinations; inclusion of a code does not guarantee reimbursement or claim payment.

Follow CPT/CMS coding guidelines when submitting claims.
Verify coverage and payment via the member-specific benefit plan document.
Inclusion of a code in this policy is not a guarantee of reimbursement.

Prior Authorization

Follow applicable LCD/LCA or delegate prior authorization requirements

Where a delegate manages utilization management and prior authorization requirements for a Medicare Advantage plan, the delegate's requirements must be followed.

For Medicare Advantage members with delegate-managed UM/PA, follow the delegate's prior authorization processes and criteria.

Background

This Medicare Advantage policy compiles Medicare guidance (National Coverage Determinations, Local Coverage Determinations/Articles) and UnitedHealthcare internal coverage criteria for select orthopedic procedures when Medicare guidance is absent or allows flexibility.

The policy is advisory: UnitedHealthcare Medicare Advantage Policies are provided for informational purposes, intended as a general reference, and do not replace Medicare source materials. They are used to support coverage decisions but are subject to change.

Benefit coverage is determined by the member-specific benefit plan document and applicable laws; in the event of a conflict, the member's benefit plan supersedes this policy.

Providers are expected to retain or have access to appropriate documentation to support coverage when requested and must follow any applicable delegate prior authorization requirements for the Medicare Advantage plan.

Definitions:

NCD: National Coverage Determination by Medicare.

LCD/LCA: Local Coverage Determination / Local Coverage Article issued by Medicare contractors.

Type (LCD/LCA)	Name	Number	Effective date
LCD	Extracorporeal Shock Wave Therapy (ESWT)	L38775
LCA	Extracorporeal Shock Wave Therapy (ESWT) Billing and Coding	A58367

Revision History

2025-12-01code_addedLatest

CPT code 27599 (Unlisted procedure, femur or knee) was added to the Applicable Codes list.

2025-12-01version_archived

Supporting Information indicates the previous policy version MMP068.08 was archived.

2025-11-12committee_approval

Policy (MMP068.09) received last committee approval on November 12, 2025.