CurrentUnitedHealthcarePolicy CS033PA.S

Surgery of the Elbow (for Pennsylvania Only)

This policy governs medical necessity and coverage considerations for elbow surgical procedures for UnitedHealthcare members in Pennsylvania, including arthroscopy and elbow arthroplasty, and describes documentation and coding references providers must follow.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Elbow (for Pennsylvania Only)

Policy CodePolicy CS033PA.S

Change TypeDocumentation clarification added

Effective DateMar 1, 2026

Next Review Date

Key ActionSupport prior authorization requests with InterQual-aligned documentation and complete medical records demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added detailed language about medical records documentation requirements to support medical necessity determinations.

Pennsylvania-onlyjurisdiction

Arthroscopy & arthroplastyprocedure types referenced

CPT listcoded procedures provided

InterQualexternal clinical criteria used

Coverage Criteria for Elbow Surgery

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Medical necessity per InterQual

Covered when medical necessity criteria are met per InterQual CP: Procedures for the listed elbow surgeries.

InterQual criteria required: Member meets the specific InterQual CP procedural criteria for the requested elbow surgery (arthroscopy, arthroplasty, or revision) as referenced in the policy.refer to InterQual

InterQual criteria are the determinative clinical coverage criteria referenced by the payer.

The list of procedure and diagnosis codes included in this policy is provided for reference only and does not guarantee coverage or payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws; some services identified by codes in this policy may be non-covered depending on those requirements.

Inclusion of a code in this policy does not imply coverage or entitlement to reimbursement. Services that do not meet the clinical criteria referenced in this policy (InterQual CP: Procedures) or that conflict with federal, state, or contractual requirements may be evaluated as not medically necessary.

Applicable Procedure Codes

Applicable CPT CodesCPT

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.
29830	Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure).
29834	Arthroscopy, elbow, surgical, with removal of loose body or foreign body.

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Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required — InterQual-based review

Prior authorization requests for elbow arthroscopy and elbow arthroplasty must be supported by documentation that meets InterQual criteria. Refer to the InterQual CP: Procedures for Arthroscopy (diagnostic and surgical) and Joint Replacement/Revision of the elbow when submitting requests. Prior authorization is required for these services when applicable under the member's benefit plan.

Affected codes include CPT 29830, 29834–29838 (elbow arthroscopy) and 24360–24371, 24365–24366 (elbow arthroplasty/arthroplasty revisions).
Click here to view the InterQual criteria.

Denial Risk

Denial Risk for Incomplete or Non-conforming Requests

Requests for services that lack supporting medical-record documentation or that do not meet InterQual clinical criteria may be denied. Ensure submitted records include all pertinent history, physical exam findings, prior conservative treatments, and results of diagnostic testing to demonstrate medical necessity.

Absence of documentation of prior conservative management (when required by InterQual) increases denial risk.
Incomplete or illegible records, or failure to produce records upon request, may result in denial of the authorization request.

Documentation Required

Medical Records Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Documentation should be legible, maintained in the patient's chart, and made available upon request.

Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
Document prior treatments and responses (e.g., conservative therapy, medications, injections, physical therapy) and rationale for surgical intervention.

Note

Provider Actions

Providers must submit complete medical records and any additional information requested during the review process. Failure to provide required documentation may delay review or lead to denial.

Submit operative reports, imaging reports, clinic notes, and therapy records as applicable.
Ensure documentation directly addresses InterQual criteria elements for the requested procedure.

Definitions and External Criteria

InterQual CP: Procedures (Referenced External Criteria)

Referenced InterQual setsInterQual CP: Procedures — Arthroscopy (diagnostic +/- synovial biopsy; surgical) and Joint Replacement/Removal or Revision (elbow).

Determinative coverage basisMedical necessity for the listed elbow procedures is determined by meeting the specific InterQual CP procedural criteria referenced in this policy.

Procedure types covered by InterQualElbow arthroscopy (diagnostic and surgical) and elbow joint replacement and revision procedures.

Provider action impliedRefer to the InterQual CP: Procedures criteria when submitting prior authorization documentation for elbow arthroscopy or arthroplasty procedures.

Where to find criteriaClick the InterQual link provided in the policy to view the full InterQual CP: Procedures sets referenced (Arthroscopy, Diagnostic +/- Synovial Biopsy, Arthroscopy Surgical, Joint Replacement, Removal/Revision).

OpenPayer

Surgery of the Elbow (for Pennsylvania Only)

Coverage Criteria for Elbow Surgery

Applicable Procedure Codes

Provider Requirements and Prior Authorization

Background

Definitions and External Criteria