CurrentUnitedHealthcarePolicy CS343ID.A

Surgery of the Hand or Wrist (Idaho-only)

Medical policy governing surgical procedures of the hand and wrist for UnitedHealthcare members in the state of Idaho, including Idaho Medicaid Plus plans; references InterQual clinical criteria for medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (Idaho-only)

Policy CodePolicy CS343ID.A

Change TypeNew Medical Policy

Effective DateJun 1, 2025

Next Review Date

Key ActionDetermine medical necessity using the referenced InterQual clinical criteria and obtain prior authorization per the member's benefit when required.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy

InterQualClinical coverage criteria source

13+ codesProcedure codes listed

IdahoGeographic applicability

06/01/2025Policy effective

Coverage and Medical Necessity

Medical Necessity per InterQual

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (Idaho-only)

Policy CodePolicy CS343ID.A

Change TypeNew Medical Policy

Effective DateJun 1, 2025

Next Review Date

Key ActionDetermine medical necessity using the referenced InterQual clinical criteria and obtain prior authorization per the member's benefit when required.

SourceLink

On This Page

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InterQual-based medical necessity: Procedure is proven and medically necessary when it meets the InterQual clinical coverage criteria referenced for the specific surgery (examples include: Arthroplasty, Metacarpophalangeal (MCP) joint; Arthroplasty, Carpometacarpal (CMC) joint of the thumb; Arthroplasty, Proximal Interphalangeal (PIP) joint; Wrist arthroscopy or arthroscopically assisted surgery; Wrist joint replacement; Removal or revision of wrist arthroplasty).Apply the specific InterQual procedure module thresholds

Provider must apply the applicable InterQual procedure module and document criteria used for the selected procedure

This policy addresses surgical procedures of the hand and wrist for UnitedHealthcare members in Idaho, including Idaho Medicaid Plus plans. It is informational and intended to assist interpretation of standard benefit plans; it does not replace or override applicable federal, state, or contractual benefit limitations. In the event of a conflict, the federal, state, or contractual requirements govern and must be referenced when determining coverage.

Inclusion of a procedure code in this policy is for reference only and does not guarantee coverage or payment. Providers should consult the member's benefit plan, applicable laws, and other UnitedHealthcare policies and guidelines to confirm coverage and reimbursement rules before delivering or billing for services.

This policy does not provide a standalone list of procedures that are explicitly designated as not medically necessary. Instead, coverage determinations are made by applying the referenced clinical criteria and by reviewing the member's specific benefit plan.

UnitedHealthcare may use third-party decision support tools (for example, InterQual) to assess medical necessity for the procedures listed. Providers should follow InterQual criteria where applicable and verify plan-specific benefit rules when submitting requests for coverage or prior authorization.

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.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization and Clinical Criteria

Prior authorization and medical necessity determinations are required and will be made by applying the InterQual clinical criteria listed for relevant procedures (for example: MCP, CMC, PIP arthroplasty; wrist arthroscopy; wrist joint replacement; removal or revision of wrist arthroplasty). Providers should obtain prior authorization when applicable and document how the InterQual criteria are met.

Prior authorization required when plan/contract mandates prior auth for surgical hand/wrist procedures.
Medical necessity will be evaluated using InterQual procedural criteria — providers must document clinical information supporting the InterQual elements.
Listing of codes in policy is informational only and does not guarantee coverage; check the member's benefit plan.
When coverage conflicts with federal, state, or contractual requirements, those requirements govern.

Note

Code Listing is Informational Only

The code listing in this policy is provided for reference purposes only. Inclusion of a code does not imply that the service is covered or that reimbursement will be provided; coverage is determined by the member’s applicable benefit plan and by federal, state, or contractual requirements.

Providers must verify coverage and prior authorization requirements with the member’s benefit plan before performing services.

Note

Reference Plan / Federal / State Requirements

This Medical Policy is intended to assist in interpreting UnitedHealthcare standard benefit plans. Always consult the applicable federal, state, and contractual requirements for the member’s benefit plan when making coverage decisions. In the event of a conflict, those requirements prevail.

UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in administering benefits.
This policy does not constitute medical advice and may be modified as necessary.

Clinical Background

Surgery of the hand or wrist encompasses a range of procedures, including arthroplasty (joint replacement), arthroscopy, synovectomy, internal fixation, and related reconstructive or revision operations. Examples covered by this policy framework include metacarpophalangeal (MCP), proximal interphalangeal (PIP), and carpometacarpal (CMC) arthroplasty; wrist arthroscopy with synovectomy or debridement; and wrist joint replacement or revision.

Medical necessity for these procedures is determined by applying established clinical coverage criteria. UnitedHealthcare references InterQual clinical criteria for the specific procedure modules named in this policy; when ALL applicable InterQual criteria are met, the procedure is considered proven and medically necessary under the policy.

Key Definitions

InterQual criteria — definition and role

DefinitionInterQual clinical criteria — a third-party, evidence‑informed clinical decision‑support tool referenced by this policy to define medical necessity for specific hand and wrist procedures (e.g., MCP, CMC, PIP arthroplasty; wrist arthroscopy; wrist joint replacement or revision).

Role in this policyMedical necessity for the listed hand and wrist surgeries is determined by applying the applicable InterQual procedure module; coverage is provided only when ALL InterQual criteria for the specific procedure are met.

Procedures covered by InterQual modules referencedArthroplasty, Metacarpophalangeal (MCP) joint; Arthroplasty, Carpometacarpal (CMC) joint (thumb); Arthroplasty, Proximal Interphalangeal (PIP) joint; Wrist arthroscopy/arthroscopically assisted surgery; Wrist joint replacement; Removal or revision of wrist arthroplasty.

How to accessThe policy directs users to 'Click here to view the InterQual criteria' for the specific procedural modules referenced.

Decision support natureInterQual is used as the clinical coverage criteria (third‑party decision support) — the policy requires application of InterQual specifics when determining procedure necessity.