The Medical Policies, corresponding update bulletins, and related Medical Benefit Injectable Policies for UnitedHealthcare Medicare Advantage plans are listed below.
A monthly notice of recently approved and/or revised UnitedHealthcare Medicare Advantage Medical Policies is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device, or procedure) in the Medical Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Medicare Advantage Medical Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 09.01.2024
Last Published 10.01.2024
Last Published 11.01.2024
Last Published 11.01.2024
These policies provide additional information on medical benefit injectables addressed in the UnitedHealthcare Medicare Advantage Medical Policies.
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Last Published 11.01.2024
Last Published 07.08.2024
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Last Published 11.01.2024
This policy addresses ambulatory electroencephalogram (EEG) monitoring to diagnose neurological conditions. Applicable Procedure Codes: 95700, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726.
Last Published 11.01.2024
This policy addresses ambulatory electrocardiographic (AECG) diagnostic procedures. Applicable Procedure Codes: 33285, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272.
Last Published 08.01.2024
This policy addresses the use of an anterior segment aqueous drainage device without extraocular reservoir. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 0671T, 66183, 66189, 66991.
Last Published 06.01.2024
This policy addresses blood-derived products for chronic non-healing wounds. Applicable Procedure Codes: G0460, G0465.
Last Published 10.01.2024
This policy addresses brow ptosis and eyelid repair. Applicable Procedure Codes: 21280, 21282, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Last Published 10.01.2024
This policy addresses capsule endoscopy and wireless gastrointestinal motility monitoring systems. Applicable Procedure Codes: 91110, 91111, 91112, 91299.
Last Published 11.01.2024
This policy addresses cardiovascular diagnostic and therapeutic procedures. Applicable Procedure Codes: 33267, 33268, 33269, 33289, 33477, 33999, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 93050, 93264, 93653, 93656, C2624.
Last Published 11.01.2024
This policy addresses Category III CPT codes used to track the utilization of emerging technologies, services, and procedures.
Last Published 11.01.2024
This policy addresses clinical diagnostic and preventive laboratory services and screenings.
Last Published 11.01.2024
This policy addresses computerized dynamic posturography (CDP) for the treatment of neurologic disease and inherited disorders, peripheral vestibular disorders, and disequilibrium in the aging/elderly. Applicable Procedure Codes: 92548, 92549.
Last Published 10.01.2024
This policy addresses computerized corneal topography. Applicable Procedure Code: 92025.
Last Published 10.01.2024
This policy addresses cosmetic and reconstructive surgical services.
Last Published 10.01.2024
This policy addresses dental services or oral surgery, temporomandibular joint (TMJ), and orthognathic surgery. Applicable Procedure Codes: 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21244, 21245, 21246, 21247, E0849, E0855, E1700, E1701, E1702.
Last Published 10.01.2024
This policy addresses specific Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), and Medical Supplies.
Last Published 10.01.2024
This policy addresses balloon sinus ostial dilation, eustachian tube dilation, functional endoscopic sinus surgery (FESS), posterior nasal nerve ablation, intranasal repair, lithotripsy for salivary stones, rhinophototherapy, rhinophyma excision, septoplasty, rhinoplasty, and vestibular stenosis repair. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520, 30540, 30545, 30620, 30999, 31240, 31242, 31243, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31287, 31288, 31295, 31296, 31297, 31298, 31299, 42699, 69705, 69706, 69799.
Last Published 10.01.2024
This policy addresses vagus nerve stimulation for treatment of chronic pain syndrome, percutaneous peripheral nerve stimulation (PNS), electrical stimulation for the treatment of dysphagia, percutaneous electrical nerve stimulation (PENS), percutaneous neuromodulation, and occipital nerve stimulation for the treatment of occipital neuralgia or headaches therapy (PNT). Applicable Procedure Codes: 61885, 61886, 63650, 64553, 64555, 64590, 64999, E0745, E0764, E0770.
Last Published 07.01.2024
This policy addresses the use of Erbitux® (cetuximab) for the treatment of colorectal cancer and head and neck cancer. Applicable Procedure Code: J9055.
Last Published 08.01.2024
This policy addresses experimental procedures and items, investigational devices, and clinical trials.
Last Published 10.01.2024
This policy addresses gastroesophageal and gastrointestinal (GI) services, procedures, and related devices. Applicable Procedure Codes: 0184T, 43647, 43648, 43881, 43882, 64590, 74261, 74262, 76497, 76498, 91132, 91133, 94595.
Last Published 10.01.2024
This policy addresses gender reassignment surgery for members with gender dysphoria.
Last Published 11.01.2024
This policy addresses genetic testing for hereditary cancer. Applicable Procedure Codes: 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0158U, 0159U, 0160U, 0161U, 0162U, 0238U, 81162, 81163, 81164, 81165, 81166.
Last Published 08.01.2024
This policy addresses insertion of aqueous drainage devices, implantation of glaucoma drainage devices, canaloplasty, and viscocanalostomy. Applicable Procedure Codes: 0449T, 0450T, 66179, 66180, 66183, 66989, 66991, 68841, C1783, L8612.
Last Published 11.01.2024
This policy addresses hearing services and devices, including hearing aids and auditory implants. Applicable Procedure Codes: 69714, L7510, L8614, L8619, L8690, L8691, L8692.
Last Published 08.01.2024
This policy addresses home health, skilled care, and related services and supplies. Applicable Procedure Codes: 97535, 99503, 99505, 99509, 99601, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0249, G0270, G0299, G0300, G0493, G0494, G0495, G0496, G2168, G2169.
Last Published 06.01.2024
This policy addresses inpatient and outpatient hospital services, outpatient observation services, religious nonmedical health care institutions (RNHCIs), long term care hospitals (LTCH), never events, emergency and urgently needed services, post-stabilization care services, follow-up care services, and ambulance services.
Last Published 06.01.2024
This policy addresses intravenous immune globulin (IVIG). Applicable Procedure Codes: C0972, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, Q2052.
Last Published 10.01.2024
This policy addresses intraocular telescope (implantable miniature telescope [IMT]) for treatment related to end-stage age-related macular degeneration. Applicable Procedure Codes: 0308T, C1840.
Last Published 06.01.2024
This policy addresses intravitreal corticosteroid implants, including Iluvien® (fluocinolone acetonide intravitreal implant). Applicable Procedure Code: J7313.
Last Published 10.01.2024
This policy addresses core decompression for avascular necrosis, hip/knee/elbow/shoulder replacement surgery (arthroplasty), endoscopic cubital tunnel release, elbow, subacromial balloon spacers for the treatment of rotator cuff tears, and radiofrequency ablation of shoulder, hip, or knee. Applicable Procedure Codes: 21299, 23470, 23472, 23929, 23929, 24360, 24361, 24362, 24363, 24365, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27299, 27299, 27412, 27415, 27416, 27445, 27446, 27447, 27486, 27487, 27599, 27599, 27700, 27702, 27703, 27899, 28446, 29819, 29820, 29821, 29823, 29824, 29825, 29827, 29828, 29830, 29834, 29835, 29836, 29837, 29838, 29840, 29843, 29844, 29845, 29846, 29847, 29848, 29850, 29851, 29855, 29856, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916, 29999, 29999, 64718.
Last Published 11.01.2024
This policy addresses outpatient medications/drugs, unlabeled use of Part B drugs, examples of covered and not covered medications/drugs, review at launch (RAL), and step therapy programs. Applicable Procedure Codes: 11980, J0596, J0597, J0598, J1290, J3490, Q2026.
Last Published 10.01.2024
This policy addresses minimally invasive procedures for treating gastroesophageal reflux disease, including endoscopic procedures, the LINX® Reflux Management System, per oral endoscopic myotomy (POEM), and transoral incisionless fundoplication (TIF). Applicable Procedures Codes: 43210, 43257, 43284, 43289, 43497, 43499, 43999, 49999.
Last Published 08.01.2024
This policy addresses molecular pathology and genetic testing when reported with unlisted codes. Applicable Procedure Codes: 81479, 81599, 84999.
Last Published 11.01.2024
This policy addresses molecular and genetic tests that have proven efficacy in the diagnosis or treatment of medical conditions.
Last Published 10.01.2024
This policy addresses neurologic services and procedures. Applicable Procedure Codes: 64568, 64999, 95965, 95966, C1827.
Last Published 10.01.2024
This policy addresses noninvasive fractional flow reserve (FFR) derived from coronary computed tomography angiography (CCTA), also known as FFR-ct, for the evaluation of ischemic heart disease/coronary artery disease. Applicable Procedure Codes: 0501T, 0502T, 0503T, 0504T, 75580.
Last Published 09.01.2024
This policy addresses certain items/services that do not have Medicare coverage criteria.
Last Published 06.01.2024
This policy addresses collagen meniscus implant, extracorporeal shock wave therapy (ESWT), bone/soft tissue healing and fusion enhancement products, manipulation under anesthesia (MUA), unicondylar spacer devices, athletic pubalgia surgery, autologous chondrocyte transplantation (knee), osteochondral grafting (knee), and open osteochondral autograft (talus). Applicable Codes: 0054T, 0055T, 0101T, 0102T, 0232T, 20985, 21073, 22505, 23700, 25259, 26340, 27198, 27275, 27570, 27599, 27860, 28635, 28890, 29799, 49659, 49999, 97139, 97799, A9999, P9020.
Last Published 10.01.2024
This policy addresses osteopathic manipulative treatments (OMT). Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929.
Last Published 10.01.2024
This policy addresses pain management, inpatient and outpatient pain rehabilitation programs, and related services. Applicable Procedure Codes: 0440T, 0441T, 0442T, 22899, 27599, 64405, 64454, 64624, 64625, 64628, 64629, 64722, 64744, 64999.
Last Published 10.01.2024
This policy addresses percutaneous coronary intervention (PCI). Applicable Procedure Codes: 92920, 92924, 92928, 92933, 92937, 92941, 92943, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608.
Last Published 11.01.2024
This policy addresses percutaneous insertion of an endovascular cardiac (ventricular) assist device. Applicable Procedure Codes: 33990, 33991, 33995.
Last Published 10.01.2024
This policy addresses pharmacogenomics testing (PGx). Applicable Procedure Codes: 0031U, 0032U, 0033U, 0117U, 0173U, 0175U, 81230, 81346, 81355.
Last Published 09.01.2024
This policy addresses platelet rich plasma injections/applications for the treatment of musculoskeletal injuries or joint conditions. Applicable Procedure Codes: M0076, P9020.
Last Published 11.01.2024
This policy addresses positron emission tomography (PET) scans for myocardial imaging.
Last Published 10.01.2024
This policy addresses services and procedures for the diagnosis and treatment of prostate conditions and related impotence treatment. Applicable Codes: 37243, 52441, 52442, 53855, 55874, 55899, 55899, 64999, L8699.
Last Published 11.01.2024
This policy addresses high-dose rate electronic brachytherapy, implantable beta-emitting microspheres for treatment of malignant tumors, transarterial chemoembolization, image guided radiation therapy (IGRT), special/associated services, standard radiation therapy (2D/3D), proton beam therapy (PBT), intensity modulated radiation therapy (IMRT), stereotactic radiosurgery/stereotactic body radiation therapy (SBRT), tumor treatment field therapy (TTFT), intraoperative hyperthermic intraperitoneal chemotherapy, and intraoperative radiation treatment (IORT) . Applicable Procedure Codes: 0394T, 0395T, 37243, 77014, 77280, 77331, 77370, 77371, 77372, 77373, 77385, 77386, 77387, 77399, 77401, 77402, 77407, 77412, 77424, 77425, 77469, 77470, 77520, 77522, 77523, 77525, 79445, A4555, E0766, G0339, G0340, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Last Published 11.01.2024
This policy addresses diagnostic radiological services. Applicable Procedure Codes: 76376, 76377, 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78099, 78199, 78226, 78227, 78299, 78399, 78451, 78452, 78469, 78494, 78499, 78579, 78580, 78582, 78597, 78598, 78599, 78608, 78699, 78799, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 78999.
Last Published 10.01.2024
This policy addresses pulmonary rehabilitation services and home use of oxygen. Applicable Procedure Codes: 31660, 31661.
Last Published 11.01.2024
This policy addresses outpatient rehabilitation therapy (including physical therapy, occupational therapy, and speech-language pathology services), inpatient rehabilitation services, and other rehabilitation therapy services. Applicable Procedure Codes: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97035, 97036, 97110, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97550, 97755, 97761, 97799, G0283.
Last Published 10.01.2024
This policy addresses skin substitutes grafts/cellular and tissue-based products (CTP) and amniotic/placental derived product injections and/or applications for non-wound musculoskeletal indications.
Last Published 11.01.2024
This policy addresses sleep apnea surgical treatments. Applicable Procedure Codes: 21141, 21145, 21196, 21199, 21685, 41512, 41530, 41599, 42145.
Last Published 10.01.2024
This policy addresses the implantation of spinal cord stimulators (SCS) for the relief of chronic intractable pain. Applicable Procedure Codes: 63650, 63655, 63685.
Last Published 10.01.2024
This policy addresses lumbar spinal fusion, cervical spinal fusion, allograft or synthetic bone graft materials, spinal decompression, interspinous process decompression, interlaminar lumbar instrumented fusion (ILIF), and percutaneous minimally invasive fusion. Applicable Procedure Codes: 0165T, 0200T, 0201T, 0219T, 0220T, 0221T, 0222T, 20930, 20931, 22206, 22207, 22212, 22222, 22214, 22224, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22556, 22558, 22610, 22612, 22630, 22633, 27279, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22842, 22849, 22850, 22852, 22854, 22855, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22867, 22868, 22869, 22870, 22899, 62287, 63003, 63005, 63012, 63016, 63017, 63030, 63042, 63046, 63047, 63050, 63051, 63055, 63056, 63064, 63077, 63085, 63087, 63090, 63101, 63102, 63170, 63173, 63185, 63190, 63191, 63197, 63200.
Last Published 10.01.2024
This policy addresses multiple surgical procedures that utilize InterQual® coverage guidelines when no Medicare coverage criteria exists.
Last Published 11.01.2024
This policy addresses Tier 2 molecular pathology procedures, which are procedures not identified by Tier 1 molecular pathology procedures or other CPT codes. Applicable Procedure Codes: 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408.
Last Published 10.01.2024
This policy addresses diagnosis, treatments, and devices for urinary and fecal incontinence. Applicable Codes: 0672T, 53860, 53899, 55899, 58999, 64561, 64581, 64590, 64595, E2001.
Last Published 11.01.2024
This policy addresses molecular urogenital/anogenital (UG/AG) panels for infectious disease pathogen identification testing. Applicable Procedure Codes: 0352U, 81513, 81514.
Last Published 10.01.2024
This policy addresses uterine services and procedures. Applicable Procedure Codes: 0071T, 0072T, 37243, 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58662, 58999, 59812, 59840.
Last Published 10.01.2024
This policy addresses treatment of varicose veins including stab phlebectomy less than 10 incisions, endomechanical ablation of incompetent extremity veins, and embolization of the ovarian and iliac veins for pelvic congestion syndrome. Applicable Procedure Codes: 36473, 36474, 37241, 37799.
Last Published 10.01.2024
This policy addresses testing for vitamin D deficiency. Applicable Procedure Code: 82652.
Last Published 06.01.2024
This policy addresses the use of zoledronic acid (Zometa® & Reclast®). Applicable Procedure Code: J3489.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s health ID card.
These UnitedHealthcare Medicare Advantage Medical Policies are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
UnitedHealthcare has developed Medicare Advantage Medical Policies to assist us in administering health benefits. These Policies are provided for informational purposes and do not constitute medical advice. Treating physicians and healthcare providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes the Medicare Advantage Medical Policy. Nothing in the Medicare Advantage Medical Policies is intended to be construed as an expansion of benefits beyond the benefits specified in the member specific benefit plan document. For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Medical Policies to comply with changes in Centers for Medicare & Medicaid Services (CMS) policy/guidelines. Medicare Advantage Medical Policies are subject to change based upon changes in Medicare's coverage requirements, changes in scientific knowledge and technology, and evolving practice patterns. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance. In the event there is a conflict between these policies and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will govern.
In the absence of an applicable National Coverage Determination (NCD), Local Coverage Determination (LCD), or other applicable Medicare guidelines, UnitedHealthcare may develop and apply internal coverage criteria as referenced in our Medicare Advantage Medical Policies. Internal coverage criteria are based on current evidence in widely used treatment guidelines or clinical literature. Widely used treatment guidelines are those developed by organizations representing clinical medical specialties and refers to guidelines for the treatment of specific diseases or conditions. Clinical literature includes large, randomized controlled trials or prospective cohort studies with clear results, published in a peer-reviewed journal, and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analyses summarizing the literature of the specific clinical question.
UnitedHealthcare's Medicare Advantage Medical Policies do not include notations regarding prior authorization requirements. View a list of services that are subject to notification/prior authorization requirements.
Medicare Advantage Medical Policies are developed as needed, regularly reviewed and updated, and subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. UnitedHealthcare may modify these policies at any time by publishing a new version of the Medicare Advantage Medical Policies on this website. The information presented in the Medicare Advantage Medical Policies is believed to be accurate and current as of the date of publication.
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