CurrentUnitedHealthcarePolicy CS343ID.A

Surgery of the Hand or Wrist (Idaho only)

Defines UnitedHealthcare Idaho medical policy for surgical procedures of the hand and wrist, including applicable CPT codes and reference to InterQual clinical criteria; applies to Idaho members including Idaho Medicaid Plus.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (Idaho only)

Policy CodePolicy CS343ID.A

Change TypeNew policy

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProviders must meet InterQual CP procedure-specific medical necessity criteria for the requested hand or wrist surgery.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy created for Surgery of the Hand or Wrist for Idaho.

InterQualClinical coverage criteria source

16+Procedure codes listed

Idaho-onlyGeographic applicability

06/01/2025Policy effective

Coverage and Medical Necessity

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

InterQual-based criteria: Surgery of the hand or wrist is medically necessary in certain circumstances as defined by the InterQual CP: Procedures lists referenced (Arthroplasty CMC thumb; Arthroplasty MCP digits; Arthroplasty PIP fingers; Arthroscopy or arthroscopically assisted wrist procedures; Diagnostic arthroscopy +/- synovial biopsy of the wrist; Joint replacement, wrist; Removal or revision of wrist arthroplasty).

Providers must satisfy the InterQual CP: Procedures criteria specific to the procedure being requested; see InterQual for the detailed clinical coverage criteria.

The inclusion of a procedure or diagnosis code in this policy is provided for reference only and does not imply that the service described by the code is a covered or non‑covered health service. Benefit coverage and claim payment are governed by applicable federal, state, or contractual requirements and laws; those requirements control in the event of a conflict.

This policy does not, by itself, declare specific services to be not medically necessary. Medical necessity determinations for surgical procedures of the hand and wrist are based on the referenced InterQual CP procedure‑specific clinical criteria; providers must meet the InterQual criteria for the specific procedure under consideration for coverage decisions.

Applicable Procedure 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

Actions Providers Must Take

Prior Authorization

InterQual-based medical necessity

Medical necessity for the procedures referenced in this policy is determined using InterQual® CP procedures (for example: arthroplasty, wrist arthroscopy, joint procedures). Providers must obtain and document InterQual-based medical necessity criteria when applicable.

InterQual® CP criteria must be referenced for determinations of medical necessity

Note

Action required: follow any provider-facing instructions or checklists included elsewhere in this document or in plan materials before submitting authorization requests or claims.

Documentation Required

Verify contractual and regulatory requirements

Verify federal, state, and plan-specific contractual requirements before applying this policy. If federal or state law or the member’s contract requires different coverage or authorization rules, those requirements take precedence.

Confirm plan-specific prior authorization and documentation rules
If there is a conflict, federal/state/contractual requirements govern

Billing Rule

Code listing is not a coverage guarantee

Listing a procedure or diagnosis code in this policy is for reference only and does not guarantee coverage or payment. Benefit coverage and medical necessity (including InterQual determinations and any plan exclusions or limits) determine whether a service will be paid.

Inclusion of a code does not imply reimbursement or a guarantee of claim payment
Other policies and guidelines and member benefits may affect coverage

Clinical Background

Surgical procedures of the hand and wrist addressed by this policy include reconstruction and replacement procedures (for example, arthroplasty of small joints such as the metacarpophalangeal and interphalangeal joints, and larger procedures including wrist arthroplasty and wrist joint revision), arthroscopy (diagnostic and therapeutic, including synovectomy, debridement, triangular fibrocartilage repair/excision, and internal fixation when performed arthroscopically), open internal fixation for fractures or instability, and removal or revision of prosthetic implants. These interventions are established treatments for specific hand and wrist conditions; this policy defers to the InterQual CP procedure‑specific medical necessity criteria to determine whether a particular procedure is covered.

Definitions

InterQual CP — definition and role

DefinitionInterQual CP: Procedures are the referenced clinical criteria sets used to establish medical necessity for the hand and wrist surgeries listed in this policy (e.g., arthroplasty CMC, MCP, PIP; wrist arthroscopy; diagnostic arthroscopy; wrist joint replacement; removal/revision of arthroplasty).

ScopeInterQual CP procedure-specific criteria determine whether a requested hand or wrist surgery is medically necessary and eligible for coverage under this policy.

Procedures referenced (examples)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.

Provider actionProviders must refer to and meet the InterQual CP: Procedures criteria applicable to the specific procedure code when requesting authorization or when documenting medical necessity.

Location of criteriaInterQual CP: Procedures — click link in the policy to view the specific InterQual criteria applied.