CurrentUnitedHealthcarePolicy CS343KS.02

Surgery of the Hand or Wrist (Kansas Only)

Defines UnitedHealthcare Kansas policy governing when surgeries of the hand or wrist are considered medically necessary, and directs use of InterQual surgical criteria; applies to members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (Kansas Only)

Policy CodePolicy CS343KS.02

Change TypeRoutine review — no material changes

Effective DateJul 1, 2025

Next Review Date

Key ActionUse the InterQual CP procedural module corresponding to the planned hand or wrist surgery to determine medical necessity for authorization.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

InterQualprimary clinical criteria source

Kansasstate applicability

17+procedure codes shown

07/01/2025policy effective date

Coverage Criteria — When Surgery of the Hand or Wrist Is Medically Necessary

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InterQual-determined Medical Necessity

Covered when InterQual CP criteria for the applicable procedure are met

InterQual-based medical necessity: Medical necessity is determined by meeting the InterQual CP criteria for the specific procedure (examples include: Arthroplasty, Carpometacarpal (CMC) Joint, Thumb; Arthroplasty, Metacarpophalangeal (MCP) Joint, Digits; Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision, Arthroplasty, Wrist).N/A

Provider must use the InterQual CP procedural module corresponding to the planned surgery to establish medical necessity.

The procedure and diagnosis codes shown in this policy are provided for reference only. Inclusion of a code in this list does not by itself indicate that the service described by the code is a covered or non‑covered health service, nor does it guarantee reimbursement. Benefit coverage is determined by applicable federal, state, and contractual requirements and other plan terms; providers should verify coverage and reimbursement with the member’s plan before billing.

Procedure and Diagnosis Codes

Applicable CPT Codes (part 1)CPT

25441	Arthroplasty with prosthetic replacement; distal radius.
25442	Arthroplasty with prosthetic replacement; distal ulna.
25443	Arthroplasty with prosthetic replacement; scaphoid carpal (navicular).
25444	Arthroplasty with prosthetic replacement; lunate.
25445	Arthroplasty with prosthetic replacement; trapezium.
25446	Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist).
25449	Revision of arthroplasty, including removal of implant, wrist joint.
26530	Arthroplasty, metacarpophalangeal joint; each joint

Applicable CPT Codes (part 2)CPT

26531	Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint.
26535	Arthroplasty, interphalangeal joint; each joint.
26536	Arthroplasty, interphalangeal joint; with prosthetic implant, each joint.
29840	Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure).
29843	Arthroscopy, wrist, surgical; for infection, lavage and drainage.
29844	Arthroscopy, wrist, surgical; synovectomy, partial.
29845	Arthroscopy, wrist, surgical; synovectomy, complete.
29846	Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement.
29847	Arthroscopy, wrist, surgical; internal fixation for fracture or instability

Provider Requirements and Considerations

Prior Authorization

InterQual criteria required for medical necessity

InterQual® criteria are required to determine medical necessity for the procedures referenced in this policy. Providers must submit documentation demonstrating that care meets the applicable InterQual CP criteria for the specific procedure requested.

Refer to InterQual CP: Procedures for the applicable surgical criteria
Attach supporting clinical documentation to prior authorization requests (history, exam, prior treatments, imaging, outcomes)

Note

Coverage determined by criteria and contract

Listing of a code in this policy does not, by itself, guarantee coverage or payment. Coverage decisions are determined by the plan’s benefit contract and applicable federal, state, or contractual requirements; medical necessity criteria (e.g., InterQual) must also be met.

Verify member benefits and contract limitations prior to scheduling or billing
A covered code under the plan still requires documentation meeting medical necessity criteria for payment consideration

Documentation Required

Check contractual/federal/state requirements

Check the member’s federal, state, or contractual benefit requirements, as these may mandate different coverage rules or override standard policy language. In the event of a conflict, federal, state, or contractual provisions govern.

Confirm state-mandated benefits or exclusions that may apply to the member
Follow any employer or contract-specific terms that alter coverage or authorization requirements

Step Therapy

Step therapy

This policy does not specify any additional step therapy requirements. If step therapy rules apply, follow InterQual criteria, plan-specific step therapy programs, and any formulary or pathway requirements in the member’s benefit contract.

No policy-level step therapy specified — follow InterQual and plan/program-specific rules where applicable
Document prior conservative therapies or steps taken when relevant to InterQual criteria or plan requirements

Background

Surgery of the hand or wrist may be medically necessary for specific clinical indications such as arthroplasty (including carpometacarpal, metacarpophalangeal, and interphalangeal joints), wrist arthroscopy for diagnostic or therapeutic procedures, and wrist joint replacement or revision. UnitedHealthcare uses the proprietary InterQual CP procedural modules to determine medical necessity for these surgeries; the planned procedure must meet the applicable InterQual criteria for authorization decisions.

Definitions

InterQual CP — definition and role

DefinitionInterQual CP is a proprietary set of procedure-level clinical criteria used by UnitedHealthcare to determine medical necessity for specific hand and wrist surgeries (examples: CMC, MCP, PIP arthroplasty; wrist arthroscopy; wrist joint replacement; revision arthroplasty).

Role in coverage decisionsMedical necessity for the applicable hand or wrist procedure is determined by meeting the corresponding InterQual CP procedural module; providers must use the InterQual CP criteria for authorization decisions.

Examples of InterQual CP modules referencedArthroplasty, Carpometacarpal (CMC) Joint, Thumb; Arthroplasty, Metacarpophalangeal (MCP) Joint, Digits; Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision, Arthroplasty, Wrist.

Action for providersRefer to and document the specific InterQual CP procedural module that corresponds to the planned surgery when requesting authorization.

AccessInterQual CP criteria are available via the InterQual resource (link provided in the policy).