CurrentUnitedHealthcarePolicy CS343KY.08

Surgery of the Hand or Wrist (Kentucky Only)

This policy governs medical necessity and coverage references for surgical procedures of the hand and wrist for UnitedHealthcare members in Kentucky. It directs use of InterQual clinical criteria for specific hand/wrist surgeries and lists applicable billing codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Hand or Wrist (Kentucky Only)

Policy CodePolicy CS343KY.08

Change TypeRoutine reviewno change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when applicable and use InterQual CP criteria to determine medical necessity for listed hand and wrist surgeries.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InterQualprimary criteria source

Kentuckystate scope

Routine reviewpolicy history

Code listcodes provided

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 medical necessity: Medical necessity for listed hand and wrist surgeries (including: Arthroplasty, Carpometacarpal (CMC) Joint, Thumb; Arthroplasty, Metacarpophalangeal (MCP) Joint, Digits; Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers; Arthroscopy or Arthroscopically Assisted Surgery, Wrist; Arthroscopy, Diagnostic, with or without Synovial Biopsy, Wrist; Joint Replacement, Wrist; Removal or Revision of Arthroplasty, Wrist) is determined by the corresponding InterQual CP criteria referenced in this policy.

Providers must use the specified InterQual CP topics for procedure-specific medical necessity determinations; obtain prior authorization per plan requirements when applicable.

The following list of procedure codes is provided for reference only. Listing a code in this policy does not imply that the service described by the code is a covered or non‑covered health service; benefit coverage is determined by the applicable federal, state, or contractual requirements and laws. The inclusion of a code does not guarantee reimbursement or claim payment and other policies or plan documents may apply.

This policy underwent a routine review on 07/01/2025 with no change to coverage guidelines. The policy does not itself enumerate specific procedures as "not medically necessary"; instead, determination of medical necessity for hand and wrist surgeries is made using the referenced InterQual CP criteria or the member’s benefit plan requirements.

Applicable Procedure and Billing Codes

Applicable CPT 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

Applicable CPT Codes (group 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 Medical Necessity via InterQual

Prior authorization and medical necessity for the hand and wrist surgeries listed in this policy are determined using InterQual® CP criteria. Providers should obtain prior authorization when required by the member's plan and submit documentation that demonstrates InterQual medical necessity criteria are met.

Providers must verify prior authorization requirements for the member's specific benefit plan before performing services.
When InterQual® criteria are not available or not applicable, UnitedHealthcare may apply other approved medical policies, Coverage Determination Guidelines, or Utilization Review Guidelines.
Submit supporting clinical documentation that addresses the InterQual® CP criteria relevant to the requested procedure.

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 that the service is covered. Benefit coverage and payment are determined by the member's federal, state, and contractual plan terms as well as applicable laws and regulations.

A code's presence in this policy does not imply coverage, reimbursement, or guarantee of claim payment.
Other UnitedHealthcare policies, state mandates, or contractual requirements may affect coverage decisions.

Note

Reference Plan / Federal / State Requirements

When determining coverage for a requested service, providers must reference and follow the applicable federal, state, and contractual requirements for the member's benefit plan. In case of any conflict between this Medical Policy and those requirements, the federal, state, or contractual requirements govern.

Check the member's specific plan terms and any state or federal mandates prior to authorization or billing.
UnitedHealthcare reserves the right to modify policies; always confirm current requirements before rendering services.

Background and Scope

Surgical procedures of the hand and wrist addressed by this policy include arthroplasty (for example, carpometacarpal, metacarpophalangeal, and interphalangeal joints), wrist arthroscopy (diagnostic and therapeutic), and wrist joint replacement or revision. Medical necessity for these specific procedures is determined by the referenced InterQual CP criteria, and the policy provides associated CPT codes for reference.

Definitions and Regulatory Notes

InterQual CP — InterQual CP criteria

DefinitionInterQual CP criteria: evidence-based clinical criteria used to determine medical necessity for specific hand and wrist procedures (e.g., CMC, MCP, PIP arthroplasty; wrist arthroscopy; wrist joint replacement and revision).

PurposeUsed as the authoritative clinical coverage criteria to determine medical necessity for listed hand and wrist surgeries referenced in this policy.

Referenced proceduresArthroplasty (CMC, MCP, PIP), wrist arthroscopy (diagnostic and surgical), wrist joint replacement, and removal/revision of wrist arthroplasty.

AccessInterQual CP topics are available via the UnitedHealthcare InterQual link provided in the policy for procedure-specific criteria.

ApplicationProviders must apply the specified InterQual topics when seeking prior authorization or when determining medical necessity for these procedures.

FDA applicability

DefinitionSurgeries of the hand or wrist are procedures and, therefore, are not regulated by the U.S. Food and Drug Administration (FDA).

Device noteDevices and instruments used during these surgeries may require FDA approval; FDA approval alone is not a basis for coverage.

Information sourceFor device-specific FDA information and premarket notifications, refer to the FDA database (example URL provided in the policy).

Policy intentThis FDA section is informational and does not determine coverage — coverage decisions are made using InterQual criteria and plan requirements.