CurrentUnitedHealthcarePolicy CS343PAG

Surgery of the Hand or Wrist (for Pennsylvania Only)

Defines UnitedHealthcare's medical policy for surgical procedures of the hand and wrist for members in Pennsylvania and references InterQual clinical criteria for medical necessity determinations. Affects providers requesting authorization and claims adjudicators for Pennsylvania members.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (for Pennsylvania Only)

Policy CodePolicy CS343PAG

Change TypeRoutine review — no material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when required and use InterQual procedural modules to document medical necessity for listed hand and wrist surgical CPT codes.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

InterQualexternal criteria source

Pennsylvaniageographic scope

CPT listcodes referenced

2025-07-01effective

Coverage Criteria

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Medical necessity criteria (InterQual-based, Pennsylvania only)

Covered when ALL of the following are met per InterQual procedural modules and Pennsylvania-specific application:

InterQual requirement: The requested hand or wrist surgical procedure meets the InterQual clinical criteria for the specific procedure (see InterQual procedural modules: Arthroplasty MCP, Arthroplasty CMC, Arthroplasty PIP, Wrist arthroscopy [diagnostic and surgical], and Wrist joint replacement).

Providers must reference the InterQual procedural modules for the detailed clinical inclusion and exclusion criteria.

Geographic applicability: The policy and InterQual-based medical necessity determinations apply only to services for members in Pennsylvania.

Requests for services that do not meet criteria set in the PARP will be evaluated on a case-by-case basis; refer to Pennsylvania Code Title 55 Chapter 1101 for exceptions.

Applicable 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.

Applicable CPT Codes (part 2)CPT

25446	Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist).
25447	Revision of arthroplasty, including removal of implant; wrist joint.
26530	Arthroplasty, metacarpophalangeal joint; each joint.
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.

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Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required (InterQual-based)

Prior authorization is required for the listed CPT procedures and UnitedHealthcare uses InterQual criteria to determine medical necessity. Providers must obtain prior authorization when required and submit clinical information necessary for InterQual review.

Affected codes: see Applicable Codes lists (CPT codes such as 25441, 25442, 25446, 26530–26536, 29840–29847, etc.)
InterQual will be used to evaluate medical necessity for the procedures listed in this policy
Obtain prior authorization before scheduling services when prior auth is required by the member's plan

Documentation Required

Coverage Decision Documentation

When making coverage determinations, document how the requested service meets federal, state, and contractual benefit requirements and include all relevant clinical records that support meeting InterQual criteria. Keep documentation available for audit and appeals.

Include clinical history, examination findings, imaging and prior treatments demonstrating criteria are met
Reference the specific InterQual criteria used to justify medical necessity in the authorization request
Retain documentation to support coverage decisions and potential post-payment review

Denial Risk

Denial Risk if InterQual Not Met

Requests that do not meet InterQual medical necessity criteria may be denied. In Pennsylvania, services that fail to meet the PARP/InterQual criteria will be evaluated per state rules and may be denied if criteria are not satisfied.

Failure to meet InterQual criteria increases the risk of denial under UnitedHealthcare and Pennsylvania-specific rules
Providers may submit additional information or appeal denials per contractual and state processes

Note

Provider Action — Verify Benefits and Submit Authorization

Providers must follow the policy instructions: verify member benefits and prior authorization requirements, use InterQual criteria for clinical justification, and ensure all submitted information aligns with federal, state, and contractual coverage requirements.

Verify plan-specific prior authorization requirements before scheduling
When required, request prior authorization and cite the InterQual criterion met
If unsure, contact UnitedHealthcare for guidance prior to performing non-emergent procedures

Background

Surgery of the hand or wrist is an established treatment option for specific pathologies and is considered medically necessary in certain circumstances. UnitedHealthcare relies on InterQual procedural modules to define the clinical criteria for common hand and wrist operations, including arthroplasty (MCP, CMC, PIP), wrist arthroscopy (diagnostic and surgical), synovectomy, and wrist joint replacement. Providers should reference the applicable InterQual modules when determining whether a requested procedure meets medical necessity.

Definitions

InterQual criteria modules — referenced procedural modules

InterQual procedural modules referencedArthroplasty, Metacarpophalangeal (MCP) joint; Arthroplasty, Carpometacarpal (CMC) joint (thumb); Arthroplasty, Proximal Interphalangeal (PIP) joint; Arthroscopy, diagnostic +/- synovial biopsy of the wrist; Arthroscopy or arthroscopically assisted surgery of the wrist; Joint replacement (wrist)

Purpose of modulesDefine clinical inclusion and exclusion criteria used to determine medical necessity for hand and wrist surgical procedures in Pennsylvania

ApplicationMedical necessity determinations for the CPT codes listed in this policy are made by applying the specific InterQual procedural modules listed above

Geographic limitationInterQual-based determinations in this policy apply only to services for UnitedHealthcare members in Pennsylvania