UnitedHealthcare Medicare Advantage medical and drug policies

Please read the terms and conditions below carefully.

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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