Surgery of the Elbow (for New Jersey Only)
Defines UnitedHealthcare medical policy for surgical procedures of the elbow for members in New Jersey, including applicability, coding references, and reliance on InterQual criteria for clinical coverage decisions.
Medical Records Documentation Used for Reviews language was added describing documentation that must support medical necessity and may be requested.
Coverage Criteria
Coverage contingent on InterQual criteria
Covered when the InterQual CP procedural criteria are met for the requested elbow surgery.
Policy defers to InterQual clinical criteria for medical necessity determinations.
The inclusion of a procedure or diagnosis code in this policy is for reference only. Listing of a code does not imply the service is covered or non‑covered. Whether a service is a covered benefit is determined by applicable federal, state, or contractual requirements and laws, which may mandate coverage for a specific service in certain circumstances. Providers should verify member benefit terms and applicable law to determine coverage and reimbursement eligibility and may be required to submit medical records as part of coverage review.
This policy relies on InterQual clinical criteria to define medical necessity for elbow surgical procedures and does not itself enumerate every condition or circumstance that might be considered not medically necessary. Non‑coverage determinations are made by applying the InterQual criteria together with the member’s benefit terms. Providers should not assume a service is non‑covered simply because it is not individually listed in this policy and should consult InterQual criteria and the member’s contract for determinations.
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