UnitedHealthcare Omnibus Codes Coverage Update

Coverage Conclusions and Evidence Summaries

Coverage conclusions (excerpt)

For each CPT/HCPCS code listed in this portion of the document the payer provides a short description and a coverage conclusion.

Per-code conclusion: Each listed code in the extracted chunks is given the conclusion 'Unproven' by UnitedHealthcare.

Providers must consult the full code-specific coverage rationale sections elsewhere in the policy for any conditions under which coverage might be allowed.

SFDI (Clarifi) - Not Medically Necessary / Unproven

Covered stance for SFDI technology

SFDI: Transcutaneous measurement of biomarkers using SFDI and multi-spectral analysis is considered unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

FDA cleared the Clarifi Imaging System (510[k]) but clinical outcome data are insufficient to establish utility.

Extracranial vertebral artery stenting - Not Medically Necessary / Unproven

Covered stance for extracranial vertebral artery stenting

Extracranial vertebral artery stenting: Transcatheter placement of extracranial vertebral artery stent(s) is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Observational registry data suggest potential benefit in acute PCTL during EVT but randomized trials are inconclusive; guidelines recommend revascularization only for recurrent symptoms despite best medical therapy.

Evidence and guideline context for vertebral artery stenting

Evidence summary and guideline context:

PCTL/VA stenting evidence: Observational registry data (pooled BASILAR and PERSIST) suggest extracranial VA stenting during EVT may improve 90-day and 1-year mRS and lower mortality without higher sICH, but limitations include retrospective design, selection bias and limited generalizability.

Supports potential benefit but calls for randomized trials.

Randomized and systematic review findings: Randomized trials and systematic reviews (e.g., VIST RCT, Cochrane review) do not show consistent significant benefit of endovascular therapy plus medical therapy versus medical therapy alone for symptomatic vertebral artery stenosis; evidence quality is low-to-moderate and inconclusive.

Uncertain or no clear net benefit in RCTs.

Guideline recommendations: ESVS 2023 advises against routine interventions for asymptomatic VA lesions and recommends considering revascularization only for recurrent vertebrobasilar symptoms despite best medical therapy; if stenting performed, consider drug-eluting stents over bare metal.

Practice guideline guidance.

Retinal prosthesis (Argus II) coverage considerations

Argus II retinal prosthesis evidence summary and regulatory context:

Device regulatory status and evidence: Argus II received an FDA Humanitarian Device Exemption (HDE) for selected severe-to-profound retinitis pigmentosa patients; manufacturing has ceased and evidence is limited to small single-arm series and case reports with some functional improvements but notable adverse events and limited controlled data.

Policy deems use unproven and not medically necessary.

Blood-based colorectal cancer biomarker panels

Blood-based biomarker panels for CRC screening:

Biomarker panel evidence: Available evidence for multi-marker blood-based CRC screening panels (e.g., BeScreened™-CRC) is insufficient; systematic reviews find few consistent biomarkers and recommend further validation in prospective screening populations.

Policy considers these tests unproven and not medically necessary.

Blood-based CRC biomarker panels — investigational/insufficient evidence

Blood-based colorectal cancer biomarker panels — coverage stance and evidence summary

General: Evidence for blood-based CRC biomarker panels is investigational/insufficient for routine CRC screening; protein-signature panels show variable AUCs in validation (examples AUCs ~0.76–0.80) but prospective screening performance and impact on outcomes are inadequate.

Further validation in pre-diagnostic, population-based cohorts required before coverage.

CAD for chest radiographs — not medically necessary / unproven

CAD for chest radiographs — coverage stance and evidence summary

General: Computer-aided detection (CAD) for chest radiographs is considered unproven and not medically necessary due to insufficient evidence that it improves diagnostic accuracy or patient outcomes; randomized trials did not show improved sensitivity or false-positive rates with AI‑CAD in an emergency department population.

Guidance bodies (NICE) and systematic reviews call for more research and do not support routine screening use.

Eyelid thermal pulsation — mixed evidence; generally unproven

Eyelid thermal pulsation (e.g., LipiFlow®) — coverage stance and evidence summary

General: Thermal pulsation devices (vectored or wearable open-eye systems) have mixed evidence: randomized trials and meta-analyses report modest short-term improvements in subjective and objective measures versus warm compresses or no treatment, but overall evidence quality is low-to-very-low and long-term benefit and generalizability are unclear; therefore routine coverage is not supported without prior conservative therapy and documentation.

Professional guidance lists VTP as a second-line option; many trials are industry-sponsored and limited by bias.

Evidence summaries informing medical necessity

Evidence summaries and trial characteristics that would inform coverage determination:

VTP efficacy evidence: Multiple RCTs and meta-analyses report that vectored thermal pulsation (LipiFlow) can improve symptom scores (OSDI, SPEED) and measures (MGYLS, TBUT) compared with warm compress or no treatment, though analyses vary by unit-of-analysis and risk of bias.

Longer-term and independently funded studies are limited.

Wearable device (TearCare) evidence: Randomized and observational studies (including SAHARA and comparative RCTs) show TearCare can improve TBUT and meibomian gland function in the short term versus comparators, but masking and long-term data are limited.

Manufacturer-funded trials predominate; durability beyond months is uncertain.

Limitations noted in evidence: Common limitations include small sample sizes, lack of masking, industry sponsorship, variable outcome measures, and limited long-term follow-up, reducing confidence in routine clinical benefit.

These limitations are cited across systematic reviews and trial reports.

Not medically necessary / unproven technologies

The document states the following technologies are considered unproven / not medically necessary:

Atherectomy (visceral/renal/abdominal/brachiocephalic): Transluminal peripheral atherectomy of visceral, renal, abdominal, or brachiocephalic arteries is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

Policy conclusion: Unproven.

PreTRM proteomic serum test: The PreTRM serum-based proteomic biomarker assay for predicting preterm birth is unproven and not medically necessary due to insufficient evidence of clinical utility.

Multiple prospective studies cited but evidence insufficient to support screening use.

Carotid sinus baroreflex activation devices: Chronic baroreceptor stimulation of the carotid sinus (baroreflex activation therapy) is unproven and not medically necessary for hypertension, heart failure, or other cardiovascular conditions due to insufficient evidence of safety and/or efficacy despite device regulatory actions.

FDA HDE and PMA exist for specific devices but policy stance remains unproven for broad coverage.

BAT coverage summary

Coverage stance and evidence summary for BAT

Indications and evidence: Randomized trials (BeAT-HF) report durable improvements in quality of life, 6MWT, and NYHA class for selected HFrEF patients, with MANCE-free rates ~97%; however, effects on mortality and HF hospitalizations are inconsistent and trials have limitations.

Policy details mixed evidence and regulatory context affecting coverage consideration.

Hypertension: For resistant hypertension, evidence is limited and inconclusive; earlier HDE approvals were narrow and guideline bodies (e.g., NICE) recommend use in research contexts only.

Policy treats carotid sinus stimulation as unproven for HTN.

Regulatory context affecting coverage: Barostim systems have HDE and PMA regulatory statuses for specified indications, which should be referenced when considering coverage, but policy continues to classify broad use as unproven outside defined indications.

Documentation of device approval status recommended for prior authorization.

Tear film imaging — Not medically necessary

Stated coverage stance from the document

Tear film imaging coverage: Tear film imaging (0330T) is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy and variable device reproducibility across platforms.

Concurrent conventional clinical assessment (slit-lamp) is recommended when evaluating dry eye; devices are not interchangeable.

123I‑MIBG imaging — Not medically necessary

Stated coverage stance from the document

Myocardial sympathetic innervation imaging coverage: Myocardial sympathetic innervation imaging with 123I‑MIBG (0331T/0332T), including planar H/M ratio and SPECT metrics, is unproven and not medically necessary as a prognostic marker in heart failure because evidence is insufficient to demonstrate changes in management that improve outcomes.H/M < 1.60

Studies report associations with outcomes but do not establish clinical utility to guide therapy.

Not medically necessary — sinus tarsi implant

Not covered (considered investigational/unproven)

Primary rationale: The use of a sinus tarsi implant (subtalar arthroereisis) is unproven and not medically necessary for any indication due to insufficient clinical evidence of safety and/or efficacy.

High implant removal rates and low-quality evidence cited in systematic reviews.

Evidence-informed coverage considerations

Summarized clinical evidence and guideline positions relevant to coverage decisions:

RDN candidate considerations: Consideration for renal denervation (RDN) should focus on patients with uncontrolled or resistant hypertension despite optimized lifestyle and guideline-directed pharmacologic therapy, with ambulatory BP confirmation and shared decision-making; device availability, regulatory approvals, and registry enrollment or research governance are important contextual requirements.

SCAI, ESC/EAPCI and NICE guidance emphasize careful selection, governance, and need for further evidence.

Subtalar arthroereisis (SA) considerations: Subtalar arthroereisis may be considered cautiously in select pediatric idiopathic flexible flatfoot refractory to conservative care, acknowledging low-quality evidence and substantial implant removal/complication rates; not supported as sole corrective procedure for stage IIB adult-acquired flatfoot.

Hayes HTA and professional consensus referenced.

RDN evidence synthesis

Evidence and guidance summary for renal denervation (RDN):

RCT outcomes: Randomized sham-controlled trials and meta-analyses show modest reductions in ambulatory and office blood pressure (typical reductions ~3–6 mmHg ambulatory; ~4/2 mmHg commonly reported), heterogeneous results across trials, and limited long-term outcome data; some trials (SYMPLICITY long-term follow-up, RADIANCE) show durable reductions in selected cohorts but overall evidence requires further high-quality studies.

Clinical guidance recommends RDN only with appropriate governance and patient selection.

RSA — not medically necessary

Radiostereometric analysis (RSA):

RSA not covered rationale: RSA is a highly precise technique used primarily in clinical research to monitor implant migration and early micromotion, but evidence is insufficient to support routine clinical use to improve patient outcomes; therefore RSA is unproven and not medically necessary for standard indications.

Technique requires implanted markers, calibration cages, specialized software, and trained staff; large RCTs linking RSA to improved outcomes are lacking.

BIA — not medically necessary

Bioelectrical impedance analysis (BIA):

BIA not covered rationale: Bioelectrical impedance analysis (0358T) for whole body composition assessment is unproven and not medically necessary due to variability with hydration status, limited clinical validity for decision-making, and insufficient evidence of improved outcomes.

Pilot studies demonstrate measurement sensitivity to recent fluid intake and other factors limiting accuracy.

Not medically necessary / Unproven positions

Not medically necessary statements included in this section:

BIA not medically necessary: Bioelectrical impedance analysis whole body composition assessment is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

0358T designated unproven.

Electronic brachytherapy not medically necessary: High dose rate electronic brachytherapy (0394T/0395T) is unproven and not medically necessary for routine treatment of breast, skin, gynecologic and other indications due to limited long-term comparative evidence; professional guidance recommends use only in trials or registries.

NCCN/ABS and ECRI assessments cited.

Covered with criteria / Conditional coverage

Coverage and clinical stance derived from evidence and guideline recommendations in the document:

Indeterminate biliary strictures: Probe-based confocal laser endomicroscopy (pCLE) may be considered as an adjunct when ERCP tissue sampling fails to diagnose indeterminate biliary strictures; meta-analyses report pooled sensitivity ~88% and specificity ~79% supporting adjunctive use in specialized settings.

Consider use where cholangioscopic access available and in experienced centers; prior authorization/documentation recommended.

Barrett's esophagus surveillance: CLE/pCLE is not recommended to routinely replace Seattle protocol biopsies; it may be used adjunctively in expert centers to target biopsies but randomized data do not show improved outcomes compared with standard protocols.

ASGE/ACG guidance advise adjunctive rather than replacement use.

Gastric and colorectal neoplasia: CLE/pCLE demonstrates high diagnostic accuracy in specialized centers for gastric cancer and colorectal neoplasms (pooled analyses report high sensitivity and specificity), but operator dependency and limited generalizability restrict routine adoption outside expert centers and trials.

Coverage stances (evidence summaries)

Summarized coverage stances and linked clinical evidence:

pCLE for Barrett's esophagus: A multicenter RCT (Wallace et al. 2012) showed no difference in outcomes when pCLE was added to high-definition white light endoscopy for detection of residual Barrett's esophagus or neoplasia; routine addition did not improve outcomes.

Study closed early for futility; not supportive of routine replacement of standard biopsy protocols.

Cardiac contractility modulation (CCM): CCM (Optimizer) is described as unproven and not medically necessary for chronic heart failure due to insufficient high-quality evidence of safety and efficacy despite PMA for selected patients; guideline assessments and recalls affect device context.

Policy classifies CCM as unproven for routine coverage.

Percutaneous cryoablation/cryoneurolysis for chronic pain: Percutaneous cryoablation/cryoneurolysis of peripheral nerves for chronic pain is unproven and not medically necessary due to limited and inconsistent clinical evidence; short-term improvements noted in some RCTs but durability and broad applicability are uncertain.

Iovera system cleared for short-term relief in knee OA but broader chronic pain indications lack robust evidence.

Not Medically Necessary determinations

Not medically necessary statements in this section

Drug-eluting ocular inserts — NMN: Placement of drug-eluting ocular inserts (0444T/0445T) is considered unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.

Policy conclusion: Unproven.

Optical coherence tomography of middle ear — NMN: Optical coherence tomography (0485T/0486T) of the middle ear is unproven and not medically necessary for assessing or managing middle ear disorders due to insufficient evidence of clinical utility and outcomes benefit.

Interim device studies show promise for diagnostic accuracy but clinical outcome data are lacking.

Prior Authorization, Documentation, and Billing Notes

Prior Authorization

Prior authorization guidance

This policy enumerates coverage conclusions and provider expectations for services addressed. Prior authorization may be required for procedures listed as requiring UnitedHealthcare prior authorization; follow standard UnitedHealthcare prior authorization processes and submit the clinical indication, supporting clinical evidence, and device FDA status when applicable.

Submit indication, supporting clinical evidence/publications, relevant prior management, and device FDA status (PMA/HDE/clearance) with prior authorization requests.
Claims for services with coverage conclusion = Unproven may be denied if billed as covered without prior authorization and supporting documentation.

Prior Authorization

Prior authorization recommended for unproven services

Prior authorization is recommended for services the policy identifies as unproven or requiring review. For these requests, include detailed clinical justification showing why conventional/standard therapies were tried and failed or are not appropriate, and reference supporting publications or guideline statements.

Examples include (but are not limited to): CAD chest radiograph codes (0174T/0175T), eyelid thermal pulsation (0207T, 0563T), tear film imaging (0330T), radiostereometric analysis (0347T–0350T), bioelectrical impedance analysis (0358T), high dose rate electronic brachytherapy (0394T/0395T), PreTRM/81599, blood-based CRC biomarker panels (0163U, 81490, 0061U), and retinal prosthesis codes (0100T, 0472T, 0473T, L8608).
For single‑procedure eyelid thermal pulsation, prior authorization should document prior conservative management (warm compresses, eyelid hygiene) and rationale for single‑procedure device therapy.

Prior Authorization

Prior authorization consideration for single‑procedure eyelid thermal pulsation

Single‑procedure eyelid thermal pulsation (e.g., LipiFlow, iLUX, TearCare) may show benefit in some trials but evidence is limited and often industry‑sponsored. Prior authorization consideration is advised when billed as a one‑time device procedure.

Document failure or intolerance of conservative therapies (warm compresses, eyelid hygiene) prior to device treatment per step‑therapy expectations.
Include clinical metrics (e.g., meibomian gland secretion score [MGS], tear breakup time, symptom scores) when available.

Prior Authorization

Prior authorization/coverage headline

Prior authorization/coverage review is expected for several headline procedures and codes identified as Unproven, Not Medically Necessary, or Covered in Certain Circumstances. Providers should anticipate scrutiny and submit robust documentation.

Headline procedures include atherectomy (0234T–0237T), carotid sinus baroreflex device codes (0266T–0273T), PreTRM and related proteomic panels (0247U, 81599), retinal prosthesis (0100T, 0472T, 0473T, L8608), and renal denervation procedures.
Codes listed as 'Covered in certain circumstances' (e.g., 93264) require documentation of the indicated conditions for coverage.

Prior Authorization

Prior authorization for listed procedure codes

For listed procedure codes where prior authorization is indicated, submit the device intended use, FDA status, and clinical rationale. Coverage decisions will consider regulatory status (PMA, HDE, 510(k)/clearance) and available clinical evidence.

Retinal prosthesis: include HDE/PMA documentation and whether patient meets device indications (e.g., Argus II HDE criteria).
CCM device/implantation codes: include device model, FDA approval/recall status, and indication documentation.
Include operative reports, device model/serial number, and manufacturer materials when applicable.

Prior Authorization

Prior authorization — unproven imaging procedures

Unproven imaging and diagnostic procedures (e.g., CAD chest radiography, tear film imaging, advanced tear imaging, myocardial sympathetic innervation imaging, middle ear OCT) are considered unproven and prior authorization requests must include strong clinical justification and reference conventional assessments first.

Tear film imaging (0330T) — preferentially perform slit‑lamp biomicroscopy and conventional clinical assessments before advanced imaging; document why advanced imaging is needed.
CAD chest radiograph codes (0174T/0175T) — CAD for chest radiographs is unproven; include justification if requested.
Middle ear OCT and automated audiometry tools — provide validation data and clinical rationale; these are at risk for denial when billed as standard care.

Prior Authorization

Prior authorization for renal denervation

Renal denervation (RDN) procedures should have prior authorization when performed outside of approved indications or clinical trials. Documentation must show prior optimized therapy and refractory status per professional guidance.

Document prior lifestyle modification and maximally tolerated pharmacologic therapy, medication adherence, ambulatory BP measurements, and shared decision‑making.
Include center qualifications, operator experience, and whether clinical governance/audit arrangements are in place as recommended by NICE.
Show specific indication: resistant or uncontrolled hypertension despite guideline‑directed therapy, or intolerance/refusal of further antihypertensive medications.

Prior Authorization

Prior authorization and review for RSA and BIA codes

Radiostereometric analysis (RSA) and bioelectrical impedance analysis (BIA) are listed as unproven and not medically necessary for routine clinical use. Prior authorization and review may be required; submit detailed RSA/BIA methodology and intended clinical impact when requesting coverage.

RSA (0347T–0350T): include marker placement details, imaging protocol, calibration cage use, software, timing of serial measurements, and how RSA results will alter management.
BIA (0358T): include device model, standardization of pre‑measurement conditions (hydration/nutrition), and rationale for how results will change clinical care.

Prior Authorization

Prior authorization recommended for CLE use

Confocal laser endomicroscopy (CLE) is considered unproven for most indications; prior authorization is recommended when used to evaluate indeterminate biliary strictures or as a substitute for surveillance. Submit diagnostic alternatives attempted and supporting literature.

When CLE is proposed for indeterminate biliary strictures, include prior ERCP/tissue sampling attempts, cholangioscopy findings, and rationale why CLE will change management.
Document if CLE use is part of research or specialized diagnostic pathway and provide protocol details.

Prior Authorization

CCM procedure codes and prior authorization note

Cardiac contractility modulation (CCM) implantation and related procedure codes are device‑specific and may require prior authorization. Include device model, FDA approval status, indication documentation, and recent device advisories/recalls.

Document NYHA class, LVEF, prior guideline‑directed medical therapy, rhythm status, and why patient is not a candidate for CRT.
Submit device details and evidence that patient meets FDA‑labeled indications.

Prior Authorization

Prior authorization — cryoneurolysis/IOvera

Cryoneurolysis (e.g., iovera system) has randomized trial evidence for some indications but remains procedure‑ and indication‑specific. Prior authorization should include trial endpoints, expected benefit duration, and conservative therapy attempts.

Document prior conservative management and duration of symptoms, target nerve(s), and expected duration of symptom relief.
Include device clearance information (e.g., iovera system FDA clearance and labeled indications) and relevant trial endpoints measured (WOMAC, VAS, functional scores).

Denial Risk

Denial risk for unproven codes

Services with a policy conclusion of Unproven or Not Medically Necessary carry a high denial risk if billed as covered. Providers should submit prior authorization requests with full supporting documentation or expect claim denial.

Examples at high denial risk: blood‑based CRC biomarker panels (0163U, 81490), PreTRM/81599, CAD chest radiograph (0174T/0175T), tear film imaging (0330T), RSA/BIA (0347T–0350T, 0358T), high dose rate electronic brachytherapy (0394T/0395T), sinus tarsi implant codes (0335T, 0510T, 0511T, S2117).
Eyelid thermal pulsation (0207T, 0563T) — denial possible when conservative management not documented.
Automated pure tone and speech audiometry and middle ear OCT are at risk for denial without validation and clinical justification.

Denial Risk

Unproven procedures may be denied

Unproven procedures may be denied when billed as covered services. Prior authorization and submission of peer‑reviewed supporting clinical evidence and regulatory device information may mitigate denial risk but do not guarantee coverage.

Provide citations to randomized trials, systematic reviews, or professional society guidance when available.
For device implants, include FDA status (PMA/HDE/clearance) and whether postapproval study commitments have been met.

Denial Risk

Retinal prosthesis not medically necessary

Retinal prosthesis (e.g., Argus II and investigational systems) are considered unproven for routine coverage; Argus II has HDE status historically and manufacturing has ceased. Prior authorization requests must document FDA HDE/PMA status and that patient meets device‑specific eligibility criteria.

Include documentation of age, visual function (bare/no light perception), prior useful form vision, lens status, and willingness/ability to participate in postimplant follow‑up and rehabilitation.
If device is investigational, include trial protocol, IRB approval, and consent documentation.

Denial Risk

Blood‑based CRC biomarker panels not medically necessary

Blood‑based colorectal cancer (CRC) biomarker panels and other multianalyte algorithmic assays are considered unproven and not medically necessary. Prior authorization requests should include analytic and clinical validation, intended use, and how results will change management.

Document intended population (screening vs diagnostic), test performance characteristics (sensitivity, specificity, PPV/NPV), and clinical utility evidence.
Examples include 0163U and related multianalyte panels (81490).

Denial Risk

CAD chest radiograph denial risk

Computer‑aided detection (CAD) for chest radiographs (0174T/0175T) is unproven and not medically necessary. Claims and prior authorization requests should include evidence of benefit over standard radiologist interpretation to be considered.

Provide comparative accuracy data and explanation of how CAD output influences clinical decisions.
If used in research or pilot contexts, include protocol and outcome measures.

Denial Risk

Eyelid thermal pulsation denial risk

Eyelid thermal pulsation procedures carry potential denial risk when conservative therapies are not documented. Include evidence of prior conservative care and objective measures when requesting coverage.

Document attempts at warm compresses, eyelid hygiene, duration of symptoms, and objective measures (MGS, tear breakup time, symptom indices).
Cite relevant trials and guideline placement of thermal pulsation as second‑line therapy.

Prior Authorization

Automated pure tone and speech audiometry

Automated pure tone and speech audiometry and other automated auditory assessment tools are emerging digital approaches and may be considered investigational; prior authorization should include validation data and intended clinical use.

Provide device validation, sensitivity/specificity, and how results will influence diagnosis or management compared with conventional audiometry conducted by an audiologist.

Denial Risk

PreTRM denial risk

PreTRM and similar proteomic predictive tests for preterm birth are unproven and not medically necessary. Prior authorization requests must include evidence of clinical validation and how test results alter management to improve outcomes.

If requesting coverage, include study data, intended clinical pathway following a positive result, and any prospective validation studies.

Documentation Required

Governance and arrangements

Governance and clinical‑arrangements expectations: for procedures judged to require special oversight (e.g., RDN, complex device implants, novel interventional procedures), document institutional governance, consenting processes, audit/research arrangements, and multidisciplinary team involvement.

Provide documentation of clinical governance, institutional experience, operator credentialing, and registry or audit plans when relevant.

Denial Risk

Claims for bioelectrical impedance analy / high dose rate electronic brachytherapy

Claims for bioelectrical impedance analysis (BIA) and high dose rate electronic brachytherapy (HDR‑eBT) are considered unproven and at risk for denial. Prior authorization requests should include device details, intended clinical impact, and supporting evidence.

BIA (0358T): include standardization of pretest hydration/nutrition and clinical rationale.
HDR‑eBT (0394T/0395T): include indication, dosimetry plans, comparative evidence to standard HDR brachytherapy or external beam therapy.

Denial Risk

Unproven / Not Medically Necessary risk

Unproven / Not Medically Necessary risk: When a procedure is listed as Unproven or Not Medically Necessary, coverage is not established and claims may be denied. Prior authorization does not guarantee payment but may allow case‑by‑case review with adequate supporting evidence.

Providers must submit peer‑reviewed evidence, guideline endorsements, and documentation of how the service will change management.
Services billed without authorization or adequate documentation are subject to denial under contractual benefit terms.

Prior Authorization

Percutaneous cryoablation of peripheral procedures

Percutaneous cryoablation of peripheral nerves or tissues (image‑guided cryoablation) and other percutaneous cryoablation procedures should include indication, target anatomy, imaging guidance details, and conservative management attempts in the prior authorization submission.

Document prior noninvasive and pharmacologic therapies and expected benefit duration.
Include imaging guidance modality, lesion size/location, and procedural safety measures.

Denial Risk

Middle ear OCT — denial risk

Middle ear OCT and other novel otologic imaging modalities are investigational. Prior authorization requests should include technical validation, clinical utility data, and how findings will alter management compared to standard otologic assessment.

Include comparative performance data with standard otoscopy/tympanometry and audiologic testing.

Documentation Required

Documentation expectations

Documentation expectations: submit complete clinical records, prior treatment history, objective measures, device regulatory status, and peer‑reviewed supporting literature to support medical necessity determinations.

Provide operative reports, imaging, device model/serial numbers, and postprocedure care plans when applicable.
Cite randomized trials, systematic reviews, professional society guidance, and device PMA/HDE/clearance documents where relevant.

Documentation Required

Device intended use and documentation

Device intended use and documentation: for device‑based therapies, include the device name, model, intended FDA‑labeled use, approval status (PMA/HDE/510(k)), and evidence that the patient meets labeled indications or trial inclusion/exclusion criteria.

Argus II: document HDE eligibility criteria, patient's preimplant visual status, and plan for postimplant rehabilitation.
For RDN and CCM, include PMA documents, patient selection criteria, and center/operator qualifications.

Documentation Required

Argus II FDA HDE eligibility documentation

Argus II FDA HDE eligibility documentation must be provided with any prior authorization request for retinal prosthesis implantation. If the device or manufacturer has ceased production, document availability and whether an investigational program is being used.

Include evidence of meeting age and vision criteria, previous useful form vision, lens status, and commitment to follow‑up and rehabilitation.
If implant is part of a clinical trial, include IRB approval, trial protocol, and consent forms.

Documentation Required

Documentation for blood‑based CRC biomarker panels

Documentation for blood‑based CRC biomarker panels should include analytic validity, clinical validity, intended screening/diagnostic population, and evidence that test results will change management to improve outcomes.

Provide sensitivity/specificity, study cohorts, prospective validation, and comparison to standard CRC screening modalities.
Explain follow‑up algorithms for positive/negative results and potential downstream interventions.

Note

Randomized trial endpoints commonly incl

Randomized trial endpoints commonly include patient‑reported outcomes, functional scores, objective physiologic measures, and safety/adverse event reporting. Submit trial endpoints and relevance to the requested service in prior authorization materials.

Examples: WOMAC, VAS, 6‑minute walk distance, ambulatory blood pressure monitoring, MGS/Tear breakup time, device‑specific functional measures.

Documentation Required

Supporting documentation

Supporting clinical evidence: include peer‑reviewed publications, systematic reviews, meta‑analyses, and guideline statements to support medical necessity. Absent high‑quality evidence, anticipate denials or requests for additional information.

Cite RCTs, well‑designed observational studies, and professional society guidance relevant to the indication.
When evidence is limited, explain the rationale for individual patient exceptions and how care will be impacted.

Documentation Required

Clinical and regulatory documentation

Clinical and regulatory documentation should accompany requests for novel devices or assays. Include FDA summaries, PMA/HDE/510(k) letters, and any postapproval study commitments when available.

For devices with PMA/HDE, attach the approval letter and labeling; for investigational devices, attach IDE/IRB documentation and trial protocol.

Documentation Required

Quantitative measures to document (H/M, SDS/TDS)

Quantitative measures to document clinical status should be submitted when relevant (e.g., Hearing thresholds, MGS, Tear breakup time [TBT], Symptom scores [SDS/TDS], ambulatory BP readings). Objective baseline and follow‑up measures strengthen the case for medical necessity.

Examples: H/M ratios in imaging, SDS/TDS for dry eye, 24‑hour ambulatory BP, WOMAC pain scores, MGS.

Prior Authorization

Conservative‑first expectation

Conservative‑first expectation: document failure, contraindication, or intolerance to conservative treatments before requesting coverage for procedural or device‑based interventions.

Examples: conservative ocular surface therapies before thermal pulsation, pharmacologic/lifestyle measures before RDN, physical therapy/orthotics before sinus tarsi implant.

Documentation Required

Device, indication, and prior management

Device, indication, and prior management: prior authorization should clearly state the device name/model, intended indication, and prior management steps taken, including dates and response to therapy.

Include prior medications, duration, adherence evidence, prior procedures, and imaging that supports the proposed intervention.

Documentation Required

RSA documentation expectations

RSA documentation expectations: when RSA is requested for clinical use, provide marker placement details, imaging calibration cage use, serial measurement timing, software used, and how RSA results will directly impact patient management.

Describe plan for baseline and follow‑up imaging, thresholds for action based on micromotion measurements, and provider expertise to interpret RSA data.

Documentation Required

Supporting clinical evidence and publica

Supporting clinical evidence and publications: include citations to key studies, meta‑analyses, and guideline statements in the prior authorization submission to facilitate timely review.

Provide full references and, when possible, copies of pivotal articles or summaries highlighting applicability to the patient.

Documentation Required

Documentation to support medical necessity

Documentation to support medical necessity should tie together the clinical problem, prior therapies, objective measures, and how the proposed service will change management or outcomes for the patient.

Include clear treatment goals, expected measurable benefit, and postprocedure follow‑up plans.

Documentation Required

Device‑specific information and FDA appr

Device‑specific information and FDA approval: when applicable, include the device's FDA approval/clearance/HDE status and labeling to demonstrate that the patient meets indications or to explain off‑label rationale.

Attach device labeling, PMA/HDE/510(k) documents, and any safety communications or recalls (e.g., CCM device recall noted January 2025).

Documentation Required

Iovera system FDA clearance and indicati

Iovera system FDA clearance and indications: when cryoneurolysis using the iovera system is proposed, include device clearance information, labeled indications, and evidence for the targeted indication.

Attach device clearance summaries and trial evidence that corresponds to the proposed use (e.g., IPBSN for knee OA).

Documentation Required

Cryoneurolysis documentation

Cryoneurolysis documentation: include target nerve, procedural technique, imaging guidance, prior conservative therapy, expected duration of benefit, and validated outcome measures used in trials.

Provide WOMAC, VAS, or other relevant outcome scores at baseline and planned follow‑up intervals.

Documentation Required

Medical therapy before vertebral artery revascularization

Medical therapy before vertebral artery revascularization: document trials of medical therapy and risk‑factor control prior to consideration of vertebral artery stenting; current guidelines discourage routine stenting for many presentations.

Include evidence of optimal medical management and documentation of recurrent vertebrobasilar symptoms despite best medical therapy when stenting is considered.

Documentation Required

Clinical guidelines (TFOS) and trials co

Clinical guidelines (e.g., TFOS, AAO) and trial data should be cited in prior authorization requests for ophthalmic and ocular surface procedures; prefer conventional assessments before advanced imaging and document adherence to guideline‑recommended stepwise care.

Document use of slit‑lamp biomicroscopy and standard clinical exams prior to advanced tear imaging or other novel ocular tests.

Documentation Required

Preferred conventional assessments before advanced tear imaging

Preferred conventional assessments before advanced tear imaging: perform and document slit‑lamp biomicroscopy, symptom questionnaires, and basic tear testing prior to ordering advanced tear film imaging.

Provide results of conventional assessments and rationale for advanced imaging when submitted for prior authorization.

Prior Authorization

Prior optimized therapy and RDN treatment pathway documentation

Prior optimized therapy and RDN treatment pathway documentation: for renal denervation, prior authorization should document medication regimens, lifestyle interventions, ambulatory BP monitoring, and rationale for RDN per consensus guidance.

Include documentation of medication classes/doses, objective adherence assessment if available, ambulatory BP readings, and multidisciplinary evaluation.

Documentation Required

For skin and breast cancer indications,

For skin and breast cancer indications and other oncologic uses of novel diagnostics or therapies, provide pathology, staging, prior treatment history, and multidisciplinary tumor board recommendations when available.

Explain how the proposed test or therapy will alter oncologic management (surgery, systemic therapy, radiation).

Step Therapy

Stepwise use after standard techniques

Stepwise use after standard techniques: for interventional or device procedures (e.g., sinus tarsi implants, CCM, RDN, cryoneurolysis), document failure of or contraindication to standard, less‑invasive treatments prior to requesting coverage.

Demonstrate prior conservative care, duration, and objective measures of treatment failure.

Note

Evidence assessments recommend further R.

Evidence assessments recommend further research for many listed technologies — when requesting prior authorization for investigational or evolving therapies, include plans for outcome measurement, registry participation, or audit to support governance and future evidence generation.

Indicate willingness to contribute data to registries or participate in structured follow‑up when appropriate.

Situations Where Use May Be Covered

General — see code-specific rationale

See code-specific rationale for details and linked evidence.

General: Refer to individual code rationale sections for clinical context, indications, and any conditional coverage statements; in this policy window most listed codes are concluded to be 'Unproven'.

Providers should consult the full policy for code-level exceptions or conditional coverage criteria.

Assessment of microvascular disease and tissue oxygenation of the foot

Potential covered indication described in code rationale (research-context evidence only).

Microvascular assessment of foot: SFDI has been evaluated to characterize microvascular disease and estimate tissue oxygenation in the foot but currently lacks prospective wound‑outcome data demonstrating improved clinical management or outcomes; considered investigational for routine clinical use.

Device cleared by FDA (Clarifi) but evidence insufficient for coverage.

Acute posterior circulation tandem lesion stroke undergoing EVT

Potential covered indication described in code rationale (acute EVT context).

Acute PCTL undergoing EVT: Observational registry data suggest extracranial vertebral artery stenting during EVT for posterior circulation tandem lesions treated within 24 hours may improve functional outcomes; however, evidence is observational and stenting remains unproven for routine elective use.<=24 hours

Consideration limited to EVT context and specialized centers; randomized data lacking.

CAD on chest radiographs for detection/triage of pulmonary nodules or lung cancer

Coverage context and evidence summary (not supportive of routine use).

CAD chest radiograph: Computer‑aided detection applied to chest radiographs for detection/triage of pulmonary nodules or lung cancer is unproven and not medically necessary; RCTs have not demonstrated improved diagnostic performance or outcomes.

NICE and systematic reviews call for more evidence; chest radiograph not recommended for lung cancer screening by guidelines.

Eyelid thermal pulsation for meibomian gland dysfunction/dry eye

Coverage context and limitations for eyelid thermal pulsation.

Eyelid thermal pulsation: Thermal pulsation for meibomian gland dysfunction/dry eye may improve signs and symptoms in some trials, but evidence is mixed and of low certainty; policy treats routine use as unproven and recommends conservative therapy trial and documentation before device therapy.

AAO and Cochrane analyses note limited long-term independent data; prior conservative measures expected.

Automated/mobile audiometry

Potential covered uses described with validation caveats.

Automated/mobile audiometry: Automated or smartphone-based audiometry demonstrates high sensitivity and specificity in multiple studies and meta-analyses for detecting hearing loss, but accuracy varies by age group, device, environment, and protocol; further validation is required before routine replacement of clinician-administered audiometry.

Accuracy lower in children/elderly and reliant on sound‑proof environment or noise‑reduction strategies.

Tear film imaging for tear film disorders

Described as investigational in code rationale; concurrent standard testing recommended.

Tear film imaging (evaluation/monitoring): Tear film imaging outputs (LLT, TMH, NIBUT, meibography) are variable across devices and not interchangeable; no validated indications demonstrate improved outcomes—considered investigational for routine monitoring or management of dry eye disease.

Conventional slit‑lamp and clinical assessments remain standard; device variability limits coverage.

Tear film imaging for evaluation or monitoring of dry eye disease

Coverage context for evaluation or monitoring of dry eye disease.

Tear film imaging may be used as an adjunct to clinical assessment in research or specialized settings to quantify tear metrics, but evidence does not support routine coverage for diagnosis or monitoring due to variable reproducibility and uncertain clinical impact.

Providers should document conventional tests and justify incremental value if requesting coverage.

123I‑MIBG planar or SPECT imaging for prognostic evaluation in heart failure

Coverage context and limits.

123I‑MIBG imaging: 123I‑MIBG planar or SPECT imaging has been associated with prognostic metrics (e.g., delayed H/M ratio <1.60 associated with higher mortality) in cohort studies, but evidence is insufficient to support routine prognostic use to guide management and improve outcomes; therefore considered unproven for routine prognostic testing in heart failure.H/M < 1.60

Quantitative measures (H/M, SDS/TDS) should be documented when submitted but do not establish coverage.

Ultrasound renal denervation for resistant or uncontrolled hypertension in trial or regulated-device contexts

Covered in trial or regulated-device contexts with documentation expectations.

Ultrasound RDN in trials/regulatory contexts: Ultrasound renal denervation (uRDN) has shown BP reductions versus sham in randomized trials (e.g., RADIANCE) at early follow-up; use outside clinical trials or without documented refractory status, ambulatory BP confirmation, and appropriate governance is considered investigational and subject to prior authorization.

Regulatory approvals (Paradise) exist; shared decision‑making and registry enrollment recommended.

RSA for research monitoring of implant migration and fracture healing

Described as appropriate in research monitoring contexts but unproven for routine clinical use.

RSA for research monitoring: Radiostereometric analysis (RSA) is appropriate and commonly used in clinical research to monitor implant migration and fracture healing with serial calibrated biplanar imaging and marker placement, but evidence does not support routine clinical use to change outcomes; coverage limited to research contexts and registries.

Requires documentation of marker placement, imaging protocol, and serial measurements.

Electronic brachytherapy clinical indications and evidence summaries

Clinical contexts discussed with evidence summaries; routine coverage limited.

Electronic brachytherapy indications: Electronic brachytherapy has limited, low-quality comparative evidence for breast, skin, and gynecologic applications; guidance and consensus statements recommend use primarily in prospective trials or registries rather than routine clinical practice.

Evidence is inconclusive and long-term outcomes lacking; coverage limited to research or select circumstances.

Indeterminate biliary strictures

Adjunctive use in selected diagnostic dilemmas described.

pCLE for indeterminate biliary strictures: Probe-based CLE may be considered when standard ERCP tissue sampling fails to establish a diagnosis of an indeterminate biliary stricture; pooled analyses report increased sensitivity compared with ERCP sampling, supporting adjunctive use in experienced centers.

Prior diagnostic workup and documentation required for prior authorization.

Barrett's esophagus surveillance — adjunctive use only

Adjunctive use only; not a replacement for standard surveillance protocols.

pCLE adjunctive for Barrett's surveillance: CLE/pCLE may be used adjunctively to target biopsies in high-prevalence or expert centers but should not replace standard Seattle protocol biopsies for Barrett's esophagus surveillance; guideline panels advise against routine replacement.

Consider only in specialized centers with experienced operators and documentation.

Gastric cancer / colorectal neoplasia — specialized center use

Specialized center use described; operator dependence noted.

CLE for gastric/colorectal neoplasia: CLE/pCLE shows high pooled diagnostic accuracy for gastric cancer and colorectal neoplasia in specialized centers (meta-analyses report high sensitivity/specificity) but operator dependence and lack of generalizability limit routine adoption; consider use in specialized centers or research registries.

Training and center experience important for diagnostic performance.

Use of probe-based confocal laser endomicroscopy (pCLE) as adjunct to high-definition white light endoscopy for detection of residual Barrett's esophagus/neoplasia

Adjunctive use described; randomized data did not show outcome benefit.

pCLE adjunct to HDWL for residual BE: A multicenter RCT found no difference in outcomes when pCLE was added to high-definition white light endoscopy for detection of residual Barrett's esophagus or neoplasia; pCLE may be used adjunctively but does not demonstrate improved outcomes over HDWL alone.

Study closed early for futility; not supportive of routine addition.

Diagnostic assessment of middle ear effusion, biofilm detection, and otologic imaging — investigational per document.

Investigational per document; diagnostic accuracy data available but clinical utility unproven.

Middle ear OCT investigational use: Optical coherence tomography (OCT) of the middle ear has demonstrated high diagnostic accuracy for detecting middle ear effusion and biofilms in early studies and may reduce antibiotic prescribing, but evidence on patient‑centered outcomes is limited and the technology remains investigational.

Interim trials show diagnostic promise (sensitivity ~90%), but clinical outcome benefit unproven.

Key Terms and Device Definitions

Bracketed language note

Purpose of bracketed languageBracketed language following unlisted code descriptions was added by UnitedHealthcare to indicate the intended use of the code within this policy.

ApplicationUsed to clarify how an unlisted procedure code is interpreted for coverage rationale in this policy window.

Provider implicationWhen submitting claims with unlisted codes, follow the bracketed description for intended use as documented by UnitedHealthcare.

Spatial Frequency Domain Imaging (SFDI)

DefinitionSpatial Frequency Domain Imaging (SFDI) is an optical, non-contact technique that quantitatively characterizes turbid tissues using multispectral analysis to estimate superficial tissue oxygenation, oxy- and deoxyhemoglobin, and related parameters.

Device exampleClarifi Imaging System uses SFDI to provide 2D/3D visual presentations of tissue oxygenation and hemoglobin parameters and is intended as part of a larger assessment battery, not a standalone diagnostic tool.

Clinical stanceUnitedHealthcare considers transcutaneous SFDI biomarker measurement unproven and not medically necessary due to insufficient evidence of safety/efficacy.

Clarifi Imaging System

DefinitionClarifi Imaging System: a non-contact, noninvasive imaging system using SFDI to report approximate superficial tissue oxygenation, oxy-hemoglobin and deoxy-hemoglobin in 2D/3D visual formats.

Intended useManufacturer indicates it is intended to determine oxygenation levels in superficial tissues for patients with potential circulatory compromise and to be used as part of a larger assessment battery.

Regulatory/diagnostic noteManufacturer states the system does not provide a medical diagnosis or prescribe treatment; clinical integration with other tests is required.

Posterior circulation tandem lesion (PCTL)

DefinitionPosterior circulation tandem lesion (PCTL): coexistence of an extracranial vertebral artery lesion and an intracranial posterior circulation occlusion in acute ischemic stroke.

Clinical relevancePCTLs are the population in which extracranial vertebral artery stenting during EVT has been evaluated in registry studies.

Humanitarian Device Exemption (HDE)

DefinitionHumanitarian Device Exemption (HDE): an FDA regulatory pathway for devices intended to treat or diagnose rare conditions where effectiveness evidence is limited.

ExampleArgus II retinal prosthesis received an HDE for select severe-to-profound retinitis pigmentosa patients.

BeScreened™-CRC

Test descriptionBeScreened™-CRC: an ELISA-based multiplexed CLIA laboratory-developed blood test measuring three plasma/serum proteins (carcinoembryonic antigen [CEA], an extracellular matrix protein, and TGDF-1/Cripto-1) with a proprietary algorithm reporting a positive/negative result for CRC/advanced adenoma likelihood.

Intended useProposed as a blood-based CRC screening panel; USPSTF does not include serum tests for CRC screening due to limited evidence.

Computer-aided detection (CAD) for chest radiographs

DefinitionComputer-aided detection (CAD) for chest radiographs: a computer algorithm that analyzes digital chest x-ray images to detect lesions and provide adjunctive findings for physician review.

Use caseIntended as an adjunct to radiologist interpretation, performed concurrently or remotely (CPT 0174T/0175T descriptions).

Policy stanceUnitedHealthcare considers CAD for chest radiographs unproven and not medically necessary due to insufficient evidence that it improves outcomes.

Vectored thermal pulsation (e.g., LipiFlow®)

DefinitionVectored thermal pulsation (e.g., LipiFlow®): a device-based treatment applying localized heat and intermittent pressure to the eyelids to evacuate meibomian glands and treat meibomian gland dysfunction (MGD).

Alternative devicesIncludes systems such as LipiFlow (VTP) and iLUX; evidence includes RCTs and systematic reviews but overall certainty is limited.

Wearable open-eye eyelid treatment (TearCare)

DefinitionWearable open-eye eyelid treatment (TearCare): a software-controlled wearable system delivering targeted, adjustable heat to the tarsal plate and meibomian glands, often followed by manual gland expression.

Evidence noteRCTs (e.g., SAHARA) and observational studies report improvements in TBUT and symptoms versus comparators, but limitations include potential bias and limited long-term data.

PreTRM proteomic test

DefinitionPreTRM: a serum-based proteomic biomarker test measuring IBP4 and SHBG, reported as a predictive risk stratification for spontaneous preterm birth.

Clinical evidenceInitial studies reported predictive performance (e.g., AUC ~0.75) but UnitedHealthcare deems PreTRM unproven and not medically necessary for routine screening.

Mobile audiometry

DefinitionMobile audiometry: automated or smartphone/tablet-based hearing threshold assessment performed on personal digital devices, with or without supervision.

Accuracy considerationsDiagnostic accuracy varies by device, testing environment, age group, and supervision; additional research needed to validate against conventional audiometry.

Baroreflex activation therapy (BAT)

DefinitionBaroreflex activation therapy (BAT): implantation of an electrical stimulator (pulse generator and lead) to stimulate carotid sinus baroreceptors to modulate autonomic tone for treatment of resistant hypertension or heart failure.

ComponentsSystem includes implantable pulse generator and lead(s) with intraoperative interrogation/programming and outpatient device evaluation codes (e.g., 0266T–0273T).

Heart‑to‑mediastinum (H/M) ratio

DefinitionHeart-to‑mediastinum (H/M) ratio: a planar 123I‑MIBG quantitative metric measuring myocardial tracer uptake relative to the mediastinum used in prognostic assessments.

Threshold contextAn H/M ratio < 1.60 has been associated with higher all‑cause and cardiac mortality and increased arrhythmic events in ADMIRE‑HF follow-up analyses, though imaging-guided management benefit is not proven.

Measurement notesStudies report use of delayed H/M ratio and SPECT-derived summed defect scores (SDS/TDS) as quantitative measures; documentation of these metrics is required when submitted for review.

Radiostereometric analysis (RSA)

DefinitionRadiostereometric analysis (RSA): a technique using implanted bone markers and calibrated biplanar radiographs analyzed by specialized software to calculate micromotion between implant and bone in 3D, typically reported as maximal total point motion (MTPM).

Use contextRoutinely used in clinical research to monitor implant migration and fracture healing; UnitedHealthcare classifies RSA as unproven for routine clinical use.

Bioelectrical impedance analysis (BIA)

DefinitionBioelectrical impedance analysis (BIA): a method estimating body composition by measuring electrical impedance to calculate total body water and derive fat‑free mass and body fat; results are sensitive to hydration and recent fluid intake.

LimitationStandardization of pre-measurement hydration/nutrition is important as fluid intake affects impedance and derived compartments.

Electronic brachytherapy

DefinitionElectronic brachytherapy: radiotherapy delivered using a miniaturized X‑ray source to deliver high dose rates close to or within target tissues as an alternative to radionuclide brachytherapy.

Clinical stanceEvidence is limited for many indications; UnitedHealthcare considers electronic brachytherapy unproven/not medically necessary for routine use in this policy window.

Confocal laser endomicroscopy (CLE)

DefinitionConfocal laser endomicroscopy (CLE): an endoscopic technique providing real‑time microscopic (optical biopsy) images of mucosa using probe‑based or integrated systems passed through an endoscope; may require intravenous fluorescein for imaging.

ApproachProbe‑based CLE (pCLE) uses a probe passed through the endoscope accessory channel to obtain high‑resolution in vivo images.

Cardiac contractility modulation (CCM)

DefinitionCardiac contractility modulation (CCM): an implanted system that delivers non‑excitatory electrical signals during the cardiac absolute refractory period to enhance myocardial contractility (e.g., Optimizer system).

Regulatory noteOptimizer CCM system has FDA PMA (P180036) for selected NYHA Class III HF patients, but UnitedHealthcare considers CCM unproven/not medically necessary for chronic heart failure in this policy window.

Iovera cryoneurolysis system

DefinitionIovera system: a cryoneurolysis device cleared by the FDA (510(k)) to produce peripheral nerve lesions by applying cold for temporary pain relief, including up to 90 days relief for knee osteoarthritis and facilitation of target nerve location via electrical nerve stimulation.

EvidenceRandomized sham‑controlled trials show short‑term pain/function improvement with effects diminishing by ~6 months; further high‑quality evidence needed.

Middle ear optical coherence tomography (OCT)

DefinitionMiddle ear OCT: optical coherence tomography imaging of the middle ear producing micron‑scale, depth‑resolved cross‑sectional images of the tympanic membrane and middle ear contents for assessment of effusion, biofilm, and otologic structures.

Clinical evidencePreliminary studies report high diagnostic accuracy for detecting middle ear effusion and potential reduction in antibiotic prescribing, but UnitedHealthcare considers middle ear OCT unproven and not medically necessary pending further evidence.

OpenPayer

Omnibus Codes (for New Mexico Only)

Coverage Conclusions and Evidence Summaries

Listed CPT / HCPCS Codes and Status

Prior Authorization, Documentation, and Billing Notes

Situations Where Use May Be Covered

Prior Authorization Rules and Notes

Contrast and Imaging Substance Notes

Key Terms and Device Definitions

Technologies and Codes Designated Not Medically Necessary

Policy Scope and Background

Frequency and Usage Limits

Policy Revision History