ModifiedUnitedHealthcarePolicy MMP052.12

Joint Procedures

Clinical coverage guidance for multiple joint surgical procedures (hip, knee, ankle, foot, hand/wrist, elbow, shoulder) including applicable CPT/HCPCS codes and references to Medicare LCDs/LCAs and InterQual where relevant; affects UnitedHealthcare providers and members.

Policy Summary

PayerUnitedHealthcare

PolicyJoint Procedures

Policy CodePolicy MMP052.12

Change TypeCoding updatereference updates

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionFollow applicable LCD/LCA and InterQual requirements and ensure documentation supports medical necessity when submitting claims.

SourceLink

POLICY UPDATE CHANGES

Removed CPT code 27445.

Updated list of documents available in the Medicare Coverage Database to reflect the most current information.

multipleanatomic areas covered

CPT/HCPCScode listings provided

Not supportedTenJet stance

1 removedcoding change

Coverage Criteria and Clinical Rationale

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General coverage statements and references

Coverage stance varies by procedure and local Medicare guidance; specific statements in the policy include:

Procedures governed by LCD/LCA: When a Medicare LCD/LCA exists for a given joint procedure (for example, some hip, knee, and shoulder procedures), compliance with that LCD/LCA is required where applicable.

For specific LCDs/LCAs, refer to the tables for Surgery of the Hip, Knee, and Shoulder.

InterQual-referenced procedures: For certain procedures without NCDs or LCDs (e.g., acetabuloplasty/resection of the femoral head and endoscopic cubital tunnel release), coverage guidance refers to InterQual criteria; providers should refer to InterQual for specific coverage criteria.

See InterQual CP: Procedures, Ulnar Nerve Decompression or Transposition, Elbow and the InterQual criteria link for acetabuloplasty.

TenJet tenotomy: Tenotomy utilizing the TenJet device for rotator cuff tendinopathy is not reasonable and necessary due to insufficient evidence of safety and/or efficacy.

Medicare does not have an NCD for TenJet; LCDs/LCAs do not exist.

Code listing disclaimer: Listing of codes is for reference only and does not itself determine coverage; benefit coverage is determined by the member's benefit plan and applicable laws.

Inclusion of a code in the policy listing does not imply coverage or guarantee payment.

TenJet clinical evidence

Coverage rationale summary for TenJet therapy

Evidence requirement: A review found insufficient clinical evidence supporting the safety and effectiveness of tenotomy utilizing the TenJet device for rotator cuff tendinopathy.

No TenJet-specific studies met inclusion in the cited systematic review (Maag et al, 2025); the TenJet system uses a 12-gauge needle with a 1.5 mm cutting window to debride tendinopathic tissue.

Tenotomy utilizing the TenJet™ device for the treatment of rotator cuff tendinopathy is not reasonable and necessary. Medicare has no National Coverage Determination (NCD) for TenJet tenotomy and there are no applicable LCDs/LCAs; however, the policy’s coverage rationale identifies that available clinical evidence is insufficient to support safety and/or effectiveness of this procedure for rotator cuff tendinopathy. Providers should follow the policy guidance when considering TenJet tenotomy and recognize that listing of codes in this policy does not itself imply coverage or guarantee payment.

A systematic review (Maag et al, 2025) evaluated ultrasound-guided percutaneous needle tenotomy techniques including PNT, TENEX, and TENJET and concluded that there is insufficient clinical evidence to support the safety and effectiveness of TenJet for tendinopathy. The review identified multiple studies using TENEX and PNT but found that no studies using the TenJet device met the inclusion criteria, leaving a lack of direct clinical data for TenJet in rotator cuff tendinopathy.

Because clinical trials and comparative studies specific to the TenJet system were not identified in the cited literature, TenJet tenotomy for rotator cuff tendinopathy is considered not reasonable and necessary due to insufficient evidence of safety and/or efficacy. This determination is based on the absence of TenJet-specific studies meeting inclusion criteria in the referenced systematic review.

The evidence base does not demonstrate adequate safety or effectiveness for TenJet tenotomy in rotator cuff tendinopathy. The TenJet system uses high-pressure saline delivered through a 12-gauge needle with a 1.5 mm cutting window to debride tendinopathic tissue, but the systematic review found no TenJet studies that met inclusion criteria, and therefore the procedure lacks sufficient clinical data to support coverage.

Applicable CPT/HCPCS Codes

Surgery of the Hip (selected CPTs)CPT

27120	Acetabuloplasty
27122	Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure)
27125	Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty)
27132	Conversion of previous hip surgery to total hip arthroplasty
27134	Revision of total hip arthroplasty; both components
27137	Revision of total hip arthroplasty; acetabular component only
27138	Revision of total hip arthroplasty; femoral component only

Femoroacetabular Impingement (FAI) SyndromeCPT

29914	Arthroscopy, hip, surgical; with femoroplasty
29915	Arthroscopy, hip, surgical; with acetabuloplasty
29916	Arthroscopy, hip, surgical; with labral repair
29999	Unlisted procedure, arthroscopy

Surgery of the KneeCPT

27412	Autologous chondrocyte implantation, knee
27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (e.g., mosaicplasty)
27446	Arthroplasty, knee, condyle and plateau; medial or lateral compartment
27447	Arthroplasty, knee, condyle and plateau; medial and lateral compartments
27486	Revision of total knee arthroplasty; 1 component
27487	Revision of total knee arthroplasty; femoral and entire tibial component
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty)
29867	Arthroscopy, knee, surgical; osteochondral allograft
29868	Arthroscopy, knee, surgical; meniscal transplantation

Surgery of the AnkleCPT

28446	Open osteochondral autograft, talus
29891	Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia
29892	Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture
29894	Arthroscopy, ankle; removal of loose body or foreign body
29895	Arthroscopy, ankle; synovectomy, partial
29897	Arthroscopy, ankle; debridement, limited
29898	Arthroscopy, ankle; debridement, extensive
29899	Arthroscopy, ankle; with ankle arthrodesis

Arthrodesis/Arthroplasty, Interphalangeal Joint, Second-Fifth ToesCPT

28899

Unlisted procedure, foot or toes

Surgery of the Hand or WristCPT

25441	Arthroplasty with prosthetic replacement; distal radius
25442	Arthroplasty with prosthetic replacement; distal ulna
25444	Arthroplasty with prosthetic replacement; lunate
25446	Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)
25449	Revision of arthroplasty, including removal of implant, wrist joint
29840	Arthroscopy, wrist, diagnostic
29844	Arthroscopy, wrist, surgical; synovectomy, partial
29845	Arthroscopy, wrist, surgical; synovectomy, complete
29846	Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage
29847	Arthroscopy, wrist, surgical; internal fixation for fracture or instability

Surgery of the Elbow / Endoscopic Cubital TunnelCPT

29999	Unlisted procedure, arthroscopy (used for endoscopic cubital tunnel release)
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
24365	Arthroplasty, radial head
29834	Arthroscopy, elbow, surgical; removal of loose body
29837	Arthroscopy, elbow, surgical; debridement, limited
29838	Arthroscopy, elbow, surgical; debridement, extensive

Surgery of the ShoulderCPT

23470	Arthroplasty, glenohumeral joint; hemiarthroplasty
23472	Arthroplasty, glenohumeral joint; total shoulder

Subacromial Balloon SpacersCPT

29999

Unlisted procedure, arthroscopy

Tenotomy Utilizing the TenJet DeviceCPTNot Covered

23929

Unlisted procedure, shoulder

HCPCS (knee biologic)HCPCS

J7330

Autologous cultured chondrocytes, implant

Applicable CPT/HCPCS codes listedmixed

24365	Arthroplasty, radial head.
29834	Arthroscopy, elbow, surgical; with removal of loose body or foreign body.
29837	Arthroscopy, elbow, surgical; debridement, limited.
29838	Arthroscopy, elbow, surgical; debridement, extensive.
23470	Arthroplasty, glenohumeral joint; hemiarthroplasty.
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement) (e.g., total shoulder).
29999	Unlisted procedure, arthroscopy.
23929	Unlisted procedure, shoulder.
J7330	Autologous cultured chondrocytes, implant.

Provider Responsibilities, Documentation, and Billing

Documentation Required

Follow LCD/LCA requirements

Where Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs) exist, providers must follow those LCD/LCA requirements. After checking the Medicare Coverage Database and the table in this policy, comply with any applicable LCD/LCA criteria; noncompliance may affect coverage and payment.

Refer to the CMS Medicare Coverage Database for the most current LCDs/LCAs.
If no applicable NCD/LCD/LCA is found, follow the Coverage Rationale in this policy.

Prior Authorization

Delegate prior authorization

For UnitedHealthcare Medicare Advantage members whose utilization management and prior authorization requirements are managed by a delegated organization, providers must follow the delegate's prior authorization processes and requirements.

Check the member's plan to determine if a delegate manages prior authorization.
Submit prior authorization requests to the delegate where applicable and retain evidence of submission and determinations.

Denial Risk

LCD/LCA compliance required

When LCDs/LCAs apply, compliance is required. Failure to follow applicable LCD/LCA requirements may result in claim denials or payment recoupment.

Document how care met the applicable LCD/LCA criteria.
Noncompliance with LCD/LCA policy language may affect Medicare Advantage payment and coverage determinations.

Billing Rule

Coding and documentation

Providers should document services using the applicable CPT, HCPCS, and ICD-10 codes; code lists in this policy are reference only and do not guarantee coverage or payment.

Use Current Procedural Terminology (CPT®) and CMS coding guidelines when reporting services.
Listing of a code in this policy does not imply the service is covered or reimbursable.

Documentation Required

Claims and documentation

Retain documentation supporting medical necessity and submit accurate claims. UnitedHealthcare may request records to verify coverage; lack of documentation or inaccurate claims may lead to denial or recoupment.

Keep clinical records, operative reports, and imaging when required to support medical necessity.
Submit claims consistent with the member's benefit plan and applicable coding guidelines.

Definitions and Procedural Notes

Acetabuloplasty / Resection of the Femoral Head (Girdlestone) — definition and InterQual reference

DefinitionAcetabuloplasty / Resection of the Femoral Head (Girdlestone): procedure for acetabuloplasty and resection of the femoral head; Medicare does not have a National Coverage Determination (NCD).

Medicare guidanceNo Medicare NCD exists for acetabuloplasty; LCDs/LCAs do not exist for this procedure.

Coverage referenceFor coverage guidelines, refer to InterQual criteria.

Femoroacetabular Impingement (FAI) Syndrome — definition and reference

DefinitionFemoroacetabular Impingement (FAI) Syndrome: condition of the hip addressed by procedures such as femoroplasty and acetabuloplasty; Medicare does not have an NCD.

Medicare guidanceNo Medicare NCD exists for FAI syndrome; LCDs/LCAs do not exist.

Coverage referenceFor coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled 'Surgery of the Hip'.

TenJet system — device description

Device typeTenJet system: high-pressure saline jet tenotomy device that delivers saline through a 2-channel, 12-gauge needle with a 1.5 mm cutting window to debride tendinopathic tissue.

MechanismDebridement of tendinopathic tissue via high-pressure saline delivered through the device's 12-gauge needle and cutting window.

Needle specification2-channel, 12-gauge needle with a 1.5 mm cutting window.

OpenPayer

Joint Procedures

Coverage Criteria and Clinical Rationale

Applicable CPT/HCPCS Codes

Provider Responsibilities, Documentation, and Billing

Background and Scope

Definitions and Procedural Notes