CurrentUnitedHealthcarePolicy N/A

UnitedHealth Premium: Specialty Episode Definitions — Neurosurgery, Orthopedics and Spine

Defines UnitedHealth Premium condition-based and procedure-based episode groupings and claims grouping timeframes for neurosurgery, orthopedics and spine specialties; affects providers and claims processing for UnitedHealthcare members and attributed physicians.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealth Premium: Specialty Episode Definitions — Neurosurgery, Orthopedics and Spine

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPhysicians may review evaluation data and submit requests for changes or corrections to episode designations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecondition-based episode categories

14/28-42claims grouping windows

AHRQ trauma & cancerexclusions noted

informationaldesignation stance

Episode Coverage Criteria

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.

Condition-Based Episode List

Condition-based episodes included in UnitedHealth Premium specialty evaluations

ALL of the following

Condition-Based Episodes
- Adult Rheumatoid Arthritis*
- Autoimmune Rheumatologic Diseases, except Lupus*
- Bursitis and Tendinitis - Elbow and Upper Arm, Bilateral
- Bursitis and Tendinitis - Elbow and Upper Arm, Single Side
- Bursitis and Tendinitis - Foot and Ankle, Bilateral
- Bursitis and Tendinitis - Foot and Ankle, Single Side
- Bursitis and Tendinitis - Hand, Wrist and Forearm, Bilateral
- Bursitis and Tendinitis - Hand, Wrist and Forearm, Single Side
- Bursitis and Tendinitis - Knee and Lower Leg, Bilateral
- Bursitis and Tendinitis - Knee and Lower Leg, Single Side
- Bursitis and Tendinitis - Shoulder
- Bursitis and Tendinitis - Thigh, Hip and Pelvis
- Bursitis and Tendinitis - Unspecified
- Carpal Tunnel Syndrome
- Complex Regional Pain Syndrome
- Conditional Exam
- Congenital Disorders of Central Nervous System
- Gout*
- Inflammation of Non-Cranial Nerves, except Carpal Tunnel
- Joint Degeneration, Localized - Back, Bilateral
- Joint Degeneration, Localized - Back, Single Side
- Joint Degeneration, Localized - Elbow and Upper Arm
- Joint Degeneration, Localized - Foot and Ankle, Bilateral
- Joint Degeneration, Localized - Foot and Ankle, Single Side
- Joint Degeneration, Localized - Hand, Wrist and Forearm
- Joint Degeneration, Localized - Knee and Lower Leg, Bilateral
- Joint Degeneration, Localized - Knee and Lower Leg, Single Side
- Joint Degeneration, Localized - Neck
- Joint Degeneration, Localized - Shoulder
- Joint Degeneration, Localized - Thigh, Hip and Pelvis
- Joint Degeneration, Localized - Unspecified*
- Joint Derangement - Elbow and Upper Arm
- Joint Derangement - Foot and Ankle
- Joint Derangement - Hand, Wrist and Forearm
- Joint Derangement - Knee and Lower Leg
- Joint Derangement - Shoulder, Bilateral
- Joint Derangement - Shoulder, Single Side
- Joint Derangement - Thigh, Hip and Pelvis, Bilateral
- Joint Derangement - Thigh, Hip and Pelvis, Single Side
- Joint Derangement - Unspecified
- Low Back Pain Syndrome
- Major Joint Inflammation - Back
- Major Joint Inflammation - Elbow and Upper Arm
- Major Joint Inflammation - Foot and Ankle
- Major Joint Inflammation - Hand, Wrist and Forearm*
- Major Joint Inflammation - Knee and Lower Leg
- Major Joint Inflammation - Other
- Major Joint Inflammation - Shoulder
- Major Joint Inflammation - Thigh, Hip and Pelvis
- Minor Orthopedic Trauma - Back
- Minor Orthopedic Trauma - Elbow and Upper Arm
- Minor Orthopedic Trauma - Foot and Ankle, Bilateral
- Minor Orthopedic Trauma - Foot and Ankle, Single Side
- Minor Orthopedic Trauma - Hand, Wrist and Forearm, Bilateral
- Minor Orthopedic Trauma - Hand, Wrist and Forearm, Single Side
- Minor Orthopedic Trauma - Head and Face
- Minor Orthopedic Trauma - Knee and Lower Leg
- Minor Orthopedic Trauma - Neck
- Minor Orthopedic Trauma - Shoulder
- Minor Orthopedic Trauma - Thigh, Hip and Pelvis, Bilateral
- Minor Orthopedic Trauma - Thigh, Hip and Pelvis, Single Side
- Minor Orthopedic Trauma - Trunk
- Minor Orthopedic Trauma - Unspecified
- Non-Malignant Neoplasm of Bone and Connective Tissue, Head and Neck
- Non-Malignant Neoplasm of Bone and Connective Tissue, Other than Head and Neck
- Non-Malignant Neoplasm of Central Nervous System
- Non-Malignant Neoplasm of Skin
- Non-Malignant Neoplasm of Skin, with Surgery, Bilateral
- Non-Malignant Neoplasm of Skin, with Surgery, Single Side
- Obesity
- Orthopedic Deformity - Back
- Orthopedic Deformity - Elbow and Upper Arm
- Orthopedic Deformity - Foot and Ankle
- Orthopedic Deformity - Hand, Wrist and Forearm
- Orthopedic Deformity - Head and Face
- Orthopedic Deformity - Knee and Lower Leg
- Orthopedic Deformity - Neck
- Orthopedic Deformity - Shoulder
- Orthopedic Deformity - Thigh, Hip and Pelvis
- Orthopedic Deformity - Trunk
- Orthopedic Deformity - Unspecified
- Orthopedic Signs and Symptoms - Back
- Orthopedic Signs and Symptoms - Elbow and Upper Arm
- Orthopedic Signs and Symptoms - Foot and Ankle
- Orthopedic Signs and Symptoms - Hand, Wrist and Forearm
- Orthopedic Signs and Symptoms - Knee and Lower Leg
- Orthopedic Signs and Symptoms - Neck
- Orthopedic Signs and Symptoms - Shoulder
- Orthopedic Signs and Symptoms - Thigh, Hip and Pelvis
- Orthopedic Signs and Symptoms - Unspecified
- Osteoporosis*
- Other Infectious Diseases
- Other Inflammation of Skin*
- Other Minor Orthopedic Disorders - Back
- Other Minor Orthopedic Disorders - Elbow and Upper Arm
- Other Minor Orthopedic Disorders - Foot and Ankle
- Other Minor Orthopedic Disorders - Hand, Wrist and Forearm
- Other Minor Orthopedic Disorders - Knee and Lower Leg
- Other Minor Orthopedic Disorders - Neck
- Other Minor Orthopedic Disorders - Shoulder
- Other Minor Orthopedic Disorders - Thigh, Hip and Pelvis
- Other Minor Orthopedic Disorders - Unspecified
- Routine Exam
- Skin Trauma, except Burn and Open Wound - Elbow and Upper Arm
- Skin Trauma, except Burn and Open Wound - Foot and Ankle, Bilateral
- Skin Trauma, except Burn and Open Wound - Foot and Ankle, Single Side
- Skin Trauma, except Burn and Open Wound - Hand and Forearm, Bilateral
- Skin Trauma, except Burn and Open Wound - Hand and Forearm, Single Side
- Skin Trauma, except Burn and Open Wound - Head and Face
- Skin Trauma, except Burn and Open Wound - Hip and Thigh
- Skin Trauma, except Burn and Open Wound - Lower Leg
- Skin Trauma, except Burn and Open Wound - Shoulder
- Skin Trauma, except Burn and Open Wound - Trunk, Bilateral
- Skin Trauma, except Burn and Open Wound - Trunk, Single Side

(List above represents the condition-based episode categories and subgroups used in UnitedHealth Premium specialty evaluations.)

Procedure Episode Grouping Rules

Procedure-based episodes with claims grouping timeframes

ALL of the following

Procedure-based episodes and per-procedure grouping windows
- Achilles Tendon Repair — .Days Before = 0; .Days After = 42 (single-side and bilateral evaluated separately).
- Ankle Ligament Repair — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Arthrodesis (including Single Joint Arthrodesis) — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Arthroscopic Removal of Foreign Body / Debridement of Shoulder — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Arthroscopic Repair Shoulder - Rotator Cuff or SLAP — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Bunionectomy — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Carpal Tunnel Release (Arthroscopy and Open) — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Cervical Spine Fusion — .Days Before = 14; .Days After = 42.
- Hip Arthroscopy and Hip Replacement (including Revision) — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Knee Arthroscopy with Cruciate Ligament Repair — .Days Before = 14; .Days After = 28 (single-side and bilateral evaluated separately).
- Knee Arthroscopy with Meniscectomy — .Days Before = 14; .Days After = 28 (single-side and bilateral evaluated separately).
- Knee Replacement Surgery — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Lumbar Decompression and Lumbar Fusion — .Days Before = 14; .Days After = 42.
- Lumbar Surgery (Curvature, Disc Disease/Radiculopathy, Postlaminectomy Syndrome, Spinal Stenosis, Spondylolisthesis) — .Days Before = 14; .Days After = 42.
- Other Arthroscopic Procedures - Shoulder — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Other Knee Arthroscopy with Treatment — .Days Before = 14; .Days After = 28 (single-side and bilateral evaluated separately).
- Rotator Cuff Repair — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Thoracic Spine Fusion — .Days Before = 14; .Days After = 42.
- Total Shoulder Replacement — .Days Before = 14; .Days After = 42 (single-side and bilateral evaluated separately).
- Vertebral Corpectomy — .Days Before = 14; .Days After = 42.

(Procedures noted are evaluated separately for single-side and bilateral when specified; claims grouping timeframes reflect the Days Before and Days After windows used to assemble procedure episodes.)

Definitions

Premium Care Physician designation

DefinitionA Premium Care Physician designation is a label applied by UnitedHealth Premium based on evaluation of episode and performance data; it is informational and not an endorsement or guarantee of quality or outcomes.

Access implicationDesignation does not limit member access — members retain access to all physicians in the UnitedHealthcare Network as described in their benefit plan.

Review and correctionPhysicians may review evaluation data and submit requests for changes or corrections to their evaluation results.

Scope of evaluationA physician may lack a designation because they were not evaluated, evaluation is in process, or there were insufficient measures, patients, or attributed episodes — this is not an indicator of quality or volume.

Claims Grouping Timeframe — definition

Definition'Days Before' and 'Days After' are the number of days prior to and following an index procedure during which related claims are grouped into the same episode.

Typical valuesMany procedures use .Days Before = 14 and .Days After = 42, but values vary by procedure (examples provided per procedure).

Procedure-specific assignmentSome procedures specify different windows (e.g., Achilles Tendon Repair: .Days Before = 0, .Days After = 42; Knee Arthroscopy with Meniscectomy: .Days Before = 14, .Days After = 28).

Single-side vs bilateralEvaluations for single-side and bilateral procedures are performed separately; claims grouping timeframes apply per specified procedure listing.

OpenPayer

UnitedHealth Premium: Specialty Episode Definitions — Neurosurgery, Orthopedics and Spine

Episode Coverage Criteria

Coding and Claims Grouping Details

Provider Review and Designation Guidance

Definitions