CurrentUnitedHealthcarePolicy CS343KY.08

Surgery of the Hand or Wrist (for Kentucky Only)

Medical policy governing surgical procedures of the hand and wrist for UnitedHealthcare Community Plan members in Kentucky; identifies applicable InterQual clinical criteria and lists relevant procedure codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (for Kentucky Only)

Policy CodePolicy CS343KY.08

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionUse InterQual CP procedure-specific criteria when requesting prior authorization for hand or wrist surgeries.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InterQualInterQual referenced

KentuckyGeographic scope

Code listCodes listed

07/01/2025Policy effective

Coverage Criteria

InterQual-based Medical Necessity

Covered when InterQual CP criteria for the specific hand or wrist procedure are met.

InterQual-based coverage: Medical necessity for hand or wrist surgeries (including but not limited to CMC arthroplasty, MCP arthroplasty, PIP arthroplasty, wrist arthroscopy (diagnostic or surgical), wrist joint replacement, and removal or revision of wrist arthroplasty) is determined by meeting the applicable InterQual CP procedure-specific criteria referenced in this policy.

Providers must consult the InterQual CP entry for the specific procedure to determine the exact clinical requirements and supporting documentation needed for coverage decisions and prior authorization.

The codes listed in this policy are provided for reference only. Listing of a code does not imply that the service described by the code is a covered or non‑covered health service, nor does inclusion guarantee reimbursement or claim payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws, and other policies or guidelines may apply when making coverage and payment determinations.

Procedure and Billing Codes

Applicable Procedure Codes (group 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

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (for Kentucky Only)

Policy CodePolicy CS343KY.08

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionUse InterQual CP procedure-specific criteria when requesting prior authorization for hand or wrist surgeries.

SourceLink

On This Page

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Provider Actions and Authorization

Denial Risk

Coverage not guaranteed by code listing

Listing a procedure or diagnosis code in this policy is for reference only and does not guarantee coverage or payment. Benefit coverage is determined by the member’s federal, state, or contractual plan terms and applicable laws. Inclusion of a code does not imply a right to reimbursement; other policies, guidelines, or benefit rules may apply.

Codes listed are not a guarantee of coverage or payment
Confirm coverage against member-specific benefit documents and applicable laws

Documentation Required

Documentation and applicability

Document clinical indications and rationale clearly when requesting prior authorization or submitting claims. Include relevant history, physical exam findings, prior conservative treatments, imaging reports, and any other information necessary to demonstrate that InterQual® clinical criteria and the member’s benefit terms are met.

Attach InterQual®-relevant documentation when available
Provide copies of prior conservative therapy, imaging, and operative planning as applicable

Prior Authorization

InterQual-based prior authorization and applicability

Prior authorization and medical necessity determinations reference InterQual® clinical practice (CP) criteria as the primary medical/surgical criteria. When InterQual® criteria apply, decisions will be made against those standards; if InterQual® lacks applicable criteria, UnitedHealthcare may apply other approved medical policies, Coverage Determination Guidelines, or Utilization Review Guidelines. Verify whether a prior authorization is required before scheduling.

InterQual® CP is the primary source for clinical determinations
If InterQual® has no applicable criteria, UnitedHealthcare may use other approved policies/guidelines
Obtain prior authorization when required by the member’s plan

Note

Provider action: verify device regulatory status when relevant

FDA approval of devices or instruments used in hand/wrist surgery is informational only and does not by itself establish coverage. Coverage determinations remain subject to the member’s benefit terms and clinical criteria.

Device FDA status does not guarantee coverage
Verify device requirements against benefit contract when relevant

Background

Surgery of the hand or wrist includes procedures such as arthroplasty (including metacarpophalangeal and interphalangeal arthroplasty), wrist arthroscopy (diagnostic and surgical procedures including synovectomy and debridement), joint replacement, and revision or removal of arthroplasty implants. This medical policy directs clinicians and reviewers to the specified InterQual® CP procedure criteria as the primary source for determining medical necessity for these hand and wrist surgeries; meeting the applicable InterQual CP criteria is required for coverage decisions.

When applying this policy, providers should use the InterQual CP entry for the specific procedure to confirm exact clinical requirements. Procedure and diagnosis code lists in this policy are for reference and do not replace the InterQual clinical criteria or applicable benefit terms when determining coverage.

Definitions

InterQual CP — definition and role

DefinitionInterQual CP is a proprietary set of procedure‑specific clinical criteria (InterQual ® CP) used by UnitedHealthcare as the primary medical/surgical criteria to determine medical necessity for hand and wrist procedures.

Scope of useApplied as the primary clinical coverage criteria for hand and wrist surgeries listed in this policy (e.g., CMC arthroplasty, MCP arthroplasty, PIP arthroplasty, wrist arthroscopy, diagnostic wrist arthroscopy with/without synovial biopsy, wrist joint replacement, and removal or revision of wrist arthroplasty).

Role in coverage determinationsMedical necessity is determined by whether the applicable InterQual CP procedure criteria are met; providers must refer to the specific InterQual entry for exact clinical requirements.

AccessThe policy directs users to the InterQual CP library (link provided in the policy) to view the detailed criteria for each listed procedure.

Relationship to policy textThis policy references InterQual CP rather than restating procedure‑specific medical necessity rules within the policy document itself.

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.