UnitedHealthcare Oxford Clinical and Administrative Policies
The Clinical Policies, Administrative Policies, and corresponding update bulletins for UnitedHealthcare Oxford plans are listed below.
To view applicable Medical Benefit Drug Policies, click here.
To view applicable Reimbursement Policies, click here.
Policy Update Bulletins
A monthly notice of recently approved and/or revised Clinical and Administrative 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 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 Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
A listing of the Oxford Policy Update Bulletins for the past two rolling years.
UnitedHealthcare® Oxford Clinical and Administrative Policies
Please read the terms and conditions below carefully.
A complete library of the UnitedHealthcare® Oxford Clinical and Administrative Policies is available here for your reference. The appearance of an item or procedure on the list indicates only that we have adopted a policy; it does not imply that we provide coverage for the item or procedure listed.
The services described in our policies are subject to the terms, conditions and limitations of the member's contract or certificate. We reserve the right, in our sole discretion, to modify policies as necessary without prior written notice unless otherwise required by our administrative procedures or applicable state law. The terms "our" and "we" include Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to self-funded members and certain insured products. Refer to the member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.
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Effective Date: 08.01.2023 – This policy addresses accreditation requirements for radiologists, radiology centers, and multi-speciality provider groups interested in participating in the UnitedHealthcare Oxford network.
Effective Date: 11.01.2023 – This policy addresses computer-assisted surgical navigation for musculoskeletal procedures and the use of intra-operative kinetic balance sensor for implant stability during knee replacement arthroplasty. Applicable Procedures Codes: 0054T, 0055T, 20985.
Effective Date: 08.01.2023 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Effective Date: 03.01.2023 – This policy addresses functional anesthetic discography (FAD), provocative discography, epiduroscopy (including spinal myeloscopy), and percutaneous and endoscopic epidural lysis of adhesions for the diagnosis or treatment of any type of neck, back, or spinal disorder. Applicable Procedure Codes: 62263, 62264, 62290, 62291, 62292, 64999, 72285, 72295.
Effective Date: 06.01.2023 – This policy addresses fecal microbiota transplantation (FMT) via enema for prevention of the recurrence of clostridioides difficile infection (CDI). Applicable Procedure Codes: 0780T, 44705, G0455.
Effective Date: 04.01.2023 – This policy addresses wearable air conduction, bone-anchored, semi-implantable hearing aids (SEHA), intraoral bone conduction, and laser or light based hearing aids, and totally implanted middle ear hearing systems.
Effective Date: 07.01.2023 – This policy addresses implanted spinal drug delivery systems for the treatment of cancer-related pain, severe spasticity, and chronic non-malignant pain. Applicable Procedure Codes: 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362.
Effective Date: 11.01.2023 – This policy addresses the use of inhaled nitric oxide (iNO) for treating term or near-term infants with hypoxic respiratory failure or echocardiographic evidence of persistent pulmonary hypertension of the newborn (PPHN). Applicable Procedure Code: 94799.
Effective Date: 10.01.2023 – This policy addresses autologous (sural) and allogenic nerve grafts to restore erectile function during or after radical prostatectomy . Applicable Procedure Codes: 55899, 64999.
Effective Date: 07.01.2023 – This policy addresses certain elective procedures that are typically performed in an office setting but may be performed in an ambulatory surgical center in certain circumstances. Applicable Procedure Codes: 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11442, 19000, 20552, 20553, 27096, 31579, 57460, 62270, 62321, 64479, 64490, 64493, 64633, 64635.
Effective Date: 11.01.2023 – This policy addresses a participating provider's use of a non-participating provider physician, facility, or other healthcare provider in a member’s care, and the Member Advanced Notice Form.
Effective Date: 10.01.2023 – This policy addresses percutaneous neuroablation for the treatment of severe cancer pain and trigeminal neuralgia. Applicable Procedure Codes: 64600, 64605, 64610, 64620, 64640.
Effective Date: 11.01.2023 – This policy addresses the use of cranial orthotic devices for treating infants following craniosynostosis surgery or for nonsynostotic (nonfusion) deformational or positional plagiocephaly. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Effective Date: 06.01.2023 – This policy addresses prostrate surgeries and interventions, including transurethral ablation, cryoablation, surgical prostatectomy, prostatic urethral lift (PUL), high-energy water vapor thermotherapy, and transperineal place
Effective Date: 04.01.2023 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Information regarding a policy or procedure that is not available online and copies of UnitedHealthcare Oxford Clinical and Administrative Policies can also be obtained by sending a written request to:
Oxford Policy Requests
4 Research Drive
Shelton, CT 06484
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.
To submit new or additional clinical evidence pertaining to a specific medical policy, click here to complete a form for UnitedHealthcare Medical Policy review. Do not submit protected health information using this form. If you have questions or concerns about a specific service for a member, refer to the appropriate Benefits, Claims, or Prior Authorization/Notification process.