RetiredUnitedHealthcarePolicy CS033LA.Q

Surgery of the Elbow (for Louisiana Only)

This policy governs UnitedHealthcare coverage guidance for surgical procedures of the elbow for Louisiana plan members; it references InterQual criteria for medical necessity and provides CPT code listings for reference.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Elbow (for Louisiana Only)

Policy CodePolicy CS033LA.Q

Change TypeRetired (policy retired Apr 1, 2026)

Effective DateMay 1, 2025 - March 31, 2026

Next Review Date

Key ActionDetermine medical necessity for elbow procedures using InterQual CP procedure-specific criteria and obtain prior authorization per plan rules.

SourceLink

POLICY UPDATE CHANGES

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

Routine review on May 1, 2025 with no change to coverage guidelines.

state-specificapplies only to

2026-04-01retirement date

InterQualmedical necessity source

CPT listprocedure codes provided

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Elbow (for Louisiana Only)

Policy CodePolicy CS033LA.Q

Change TypeRetired (policy retired Apr 1, 2026)

Effective DateMay 1, 2025 - March 31, 2026

Next Review Date

Key ActionDetermine medical necessity for elbow procedures using InterQual CP procedure-specific criteria and obtain prior authorization per plan rules.

SourceLink

On This Page

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Covered with criteria

Covered when InterQual CP procedure-specific criteria are met.

InterQual-based medical necessity: Medical necessity for diagnostic and surgical elbow arthroscopy, joint replacement, and removal/revision of elbow arthroplasty is determined by meeting the applicable InterQual CP: Procedures criteria listed in the policy.

Refer to the InterQual CP: Procedures (Arthroscopy, Diagnostic +/- Synovial Biopsy, Elbow; Arthroscopy, Surgical, Elbow; Joint Replacement, Elbow; Removal or Revision, Arthroplasty, Elbow) for detailed clinical criteria and required findings.

This policy does not itemize every scenario that would be considered not medically necessary. Medical necessity determinations for elbow procedures are made by applying the applicable InterQual® CP: Procedures criteria. Procedures that do not meet the InterQual clinical coverage criteria or that conflict with federal, state, or contractual benefit terms would not be covered.

Providers should verify member benefits and applicable plan or regulatory requirements prior to rendering services, since those terms may supersede the guidance in this policy.

Coding and Procedure Codes

Arthroscopy CPT Codes (reference)CPT

29830	Arthroscopy, Surgical, Elbow, Description = Arthroscopy, Surgical, Elbow.
29834	Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure).
29835	Arthroscopy, elbow, surgical ; with removal of loose body or foreign body.
29836	Arthroscopy, elbow, surgical; synovectomy, partial.
29837	Arthroscopy, elbow, surgical; synovectomy, complete.
29838	Arthroscopy, elbow, surgical ;debridement, limited.
29838.1	Arthroscopy, elbow, surgical ;debridement, extensive.

Elbow Arthroplasty CPT Codes (reference)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 & Prior Authorization

Prior Authorization

InterQual-based medical necessity (prior authorization implication)

Medical necessity for elbow procedures referenced in this policy is determined using InterQual® CP procedure criteria. Providers should obtain prior authorization when required by the member’s plan and submit clinical information that demonstrates the case meets the applicable InterQual procedure criteria (for example: Diagnostic Arthroscopy Elbow; Surgical Arthroscopy Elbow; Elbow Joint Replacement; Removal/Revision Arthroplasty Elbow).

Affected procedures: elbow arthroscopy (diagnostic and surgical), elbow joint replacement, removal/revision of elbow arthroplasty
Prior authorization may be required per plan benefits and InterQual-based medical necessity determination

Denial Risk

Denial risk tied to InterQual criteria

Coverage is limited to members whose documentation meets the InterQual clinical coverage criteria noted in this policy. Lack of documentation or failure to meet those criteria may result in claim denial or authorization denial. Providers should ensure submitted records clearly document the clinical findings, prior conservative treatments (when applicable), and the specific InterQual criteria met.

Denials may occur when documentation does not support InterQual criteria or plan benefit rules
Include operative notes, imaging reports, prior treatment history, and objective functional limitations as applicable

Documentation Required

Required documentation & benefit verification

Verify member benefits, prior authorization requirements, and any federal, state, or contractual terms before scheduling services. Document clinical findings, imaging, prior conservative management, and rationale showing how the case meets the specific InterQual procedure criteria. Retain and submit all supporting records with prior authorization requests or claims as required by the plan.

Confirm whether the member’s plan requires prior authorization and the correct authorization route
Attach relevant clinical documentation: history, exam, imaging, conservative therapy records, and operative reports
Be aware that federal/state/contractual terms may override this policy

Step Therapy

Step therapy

This policy does not specify step therapy requirements. Where the member’s plan imposes step therapy or conservative therapy prerequisites for surgical consideration, those plan-specific rules apply and must be met in addition to InterQual criteria.

No step therapy mandated by this policy; check the member’s benefit plan for any conservative therapy requirements prior to authorization
If step therapy is required by the plan, document completed steps when submitting authorization requests

Background

Surgical procedures of the elbow covered under the InterQual procedure-specific criteria include diagnostic arthroscopy (with or without synovial biopsy), surgical elbow arthroscopy (including removal of loose bodies, partial or complete synovectomy, and limited or extensive debridement), and elbow arthroplasties such as total elbow and radial head replacement as well as revisions/removals of prior arthroplasty. Refer to the InterQual CP: Procedures listed in this policy for the detailed clinical coverage criteria that define when these procedures are medically necessary.

Definitions

Elbow arthroscopy — definition/description

TermElbow arthroscopy

DefinitionIncludes diagnostic arthroscopy with or without synovial biopsy, and surgical arthroscopy procedures such as removal of loose bodies or foreign bodies, partial or complete synovectomy, and debridement (limited or extensive).

Typical CPT codes (reference)29830, 29834, 29835, 29836, 29837, 29838

Elbow arthroplasty — definition/description

TermElbow arthroplasty

DefinitionArthroplasty (joint replacement) of the elbow, including procedures such as distal humeral prosthetic replacement, total elbow prosthetic replacement, radial head arthroplasty, and revisions of total elbow arthroplasty.

Typical CPT codes (reference)24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371

OpenPayer