The Medical Management Guidelines and corresponding update bulletins for UnitedHealthcare West are listed below.
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A monthly notice of recently approved and/or revised Medical Management Guidelines (MMGs) 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 Management Guideline 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 Medical Management Guideline Update Bulletin and the posted guideline, the provisions of the posted guideline will prevail.
10/01/2019 – UnitedHealthcare West Medical Management Guideline Update Bulletin: October 2019
Last Modified 10.01.2019
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Medical Management Guidelines.
11/01/2019 – UnitedHealthcare West Medical Management Guideline Update Bulletin: November 2019
Last Modified 11.01.2019
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Medical Management Guidelines.
12/01/2019 – UnitedHealthcare West Medical Management Guideline Update Bulletin: December 2019
Last Modified 12.01.2019
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Medical Management Guidelines.
UnitedHealthcare West Medical Management Guideline Update Bulletin Archive
Last Modified 12.01.2019
Current Medical Management Guidelines
UnitedHealthcare West Medical Management Guidelines
Please Read the Terms and Conditions Below Carefully.
UnitedHealthcare has developed Medical Management Guidelines to assist us in administering health benefits. These guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care 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.
Our Medical Management Guidelines express our determination of whether a health service (e.g., test, drug, device or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered. The Medical Management Guidelines are also used to determine whether a service falls within a benefit category or is excluded from coverage. They may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.
Benefit coverage for health services is determined by the member specific benefit plan document, such as an Evidence of Coverage or Schedule of Benefits, 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 these guidelines. The Medical Management Guidelines do not replace an individualized case-by-case review and medical necessity determination for each UnitedHealthcare® West member.
Medical Management Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Medical Management Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. The MCG™ Care Guidelines are proprietary to MCG™ and are not published on this website. Health Plan coverage is provided by or through UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas, Inc., and UnitedHealthcare of Washington, Inc.
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Ablative Treatment for Spinal Pain – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses thermal radiofrequency ablation and other facet joint nerve ablation procedures for spinal pain. Applicable Procedure Codes: 22899, 64633, 64634, 64635, 64636, 64999.
Abnormal Uterine Bleeding and Uterine Fibroids – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses the use of levonorgestrel-releasing intrauterine devices (LNG-IUD), uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound ablation (MRgFUS), and ultrasound-guided radiofrequency ablation. Applicable Procedure Codes: 0071T, 0072T, 0404T, 37243, 58578, 58674, 58999, J7296, J7297, J7298, J7301, J7306, S4981.
Apheresis – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses apheresis/therapeutic apheresis. Applicable Procedure Codes: 0342T, 36511, 36512, 36513, 36514, 36516, 36522, S2120.
Athletic Pubalgia Surgery – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses surgical repair for treating athletic pubalgia. Applicable Procedure Codes: 49659, 49999.
Attended Polysomnography for Evaluation of Sleep Disorders – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses home sleep apnea testing, attended full-channel nocturnal polysomnography performed in a healthcare facility or laboratory setting, daytime sleep studies, and attended PAP titration. Applicable Procedure Codes: 95782, 95783, 95800, 95801, 95803, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
Autologous Chondrocyte Transplantation in the Knee – UnitedHealthcare West Medical Management Guideline
Last Modified 09.25.2019
Effective Date: 01.01.2019 – This policy addresses autologous chondrocyte transplantation (ACT). Applicable Procedure Codes: 27412, J7330, S2112.
Balloon Sinus Ostial Dilation – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses balloon sinus ostial dilation. Applicable Procedure Codes: 31295, 31296, 31297, 31298.
Bariatric Surgery – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses bariatric surgical procedures, including gastric bypass, gastric banding, gastric sleeve procedure, biliopancreatic bypass, and biliopancreatic diversion with duodenal switch.
Blepharoplasty, Blepharoptosis and Brow Ptosis Repair – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 07.01.2019 – This policy addresses upper and lower eyelid blepharoplasty, upper eyelid blepharoptosis repair, brow ptosis, eyelid surgery with an anophthalmic socket, ectropion or punctal eversion, entropion, lid retraction surgery, canthoplasty/canthopexy, and repair of floppy eyelid syndrome (FES). Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Bone or Soft Tissue Healing and Fusion Enhancement Products – UnitedHealthcare West Medical Management Guideline
Last Modified 04.01.2019
Effective Date: 04.01.2019 – This policy addresses autographs, allografts, demineralized bone matrix (DBM), bone morphogenetic proteins (BMP), and other bone or soft tissue healing and fusion enhancement products. Applicable Procedure Codes: 0232T, 20930, 20931, 20932, 20933, 20934, 22558, 22585, 22899, Q4100, Q4149, Q4186, Q4187.
Breast Imaging for Screening and Diagnosing Cancer – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 05.01.2019 – This policy addresses breast imaging, including digital mammography, magnetic resonance imaging (MRI), ultrasound, automated breast ultrasound system, computer-aided detection (CAD), computer-aided tactile breast imaging, electrical impedance scanning (EIS), magnetic resonance elastography (MRE), and scintimammography. Applicable Procedure Codes: 0422T, 76376, 76377, 76391, 76498, 76499, 76641, 76642, 77046, 77047, 77048, 77049, 77065, 77066, 77067, S8080.
Breast Reconstruction Post Mastectomy – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses breast reconstruction post-mastectomy. Applicable Procedure Codes: 11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 19316, 19318, 19324, 19325, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 19396, 19499, L8600, S2066, S2067, S2068, S8950.
Breast Reduction Surgery – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses breast reduction surgeries. Applicable Procedure Code: 19318.
Breast Repair/Reconstruction Not Following Mastectomy – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses breast repair/reconstruction not following mastectomy. Applicable Procedure Codes: 19328, 19330, 19355, 19370, 19371, 19380.
Bronchial Thermoplasty – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses bronchial thermoplasty. Applicable Procedure Codes: 31660, 31661.
Cardiac Event Monitoring – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses cardiac event monitoring, including ambulatory event monitoring, outpatient cardiac telemetry, and implantable loop recorder. Applicable Procedure Codes: 0295T, 0296T, 0297T, 0298T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93268, 93270, 93271, 93272, 93285, 93291, 93298, 93299, E0616.
Cardiovascular Disease Risk Tests – UnitedHealthcare West Medical Management Guideline
Last Modified 01.01.2019
Effective Date: 01.01.2019 – This policy addresses arterial compliance testing using waveform analysis, carotid intima-media thickness (CIMT) measurement, advanced lipoprotein analysis, endothelial function assessment, and tests for lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme, other human A2 phospholipases, and long-chain omega-3 fatty acids. Applicable Procedure Codes: 0052U, 0111T, 0126T, 0423T, 82172, 83695, 83698, 83701, 83704, 93050, 93799, 93895, 93998.
Carrier Testing for Genetic Diseases – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 07.01.2019 – This policy addresses the Ashkenazi Jewish carrier screening and expanded carrier screening panel testing. Applicable Procedure Codes: 81412, 81443, 81479.
Chelation Therapy for Non-Overload Conditions – UnitedHealthcare West Medical Management Guideline
Last Modified 03.01.2019
Effective Date: 03.01.2019 – This policy addresses chelation therapy. Applicable Procedure Codes: J3490, M0300, S9355.
Chemosensitivity and Chemoresistance Assays in Cancer – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses chemosensitivity and chemoresistance assays in cancer. Applicable Procedure Codes: 0083U, 81535, 81536, 86849, 89240.
Chemotherapy Observation or Inpatient Hospitalization – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 05.01.2019 – This policy addresses chemotherapy observation or overnight (inpatient) stay.
Chromosome Microarray Testing (Non-Oncology Conditions) – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses genome-wide comparative genomic hybridization microarray testing or single nucleotide polymorphism (SNP) chromosomal microarray analysis. Applicable Procedure Codes: 81228, 81229, 81479, S3870.
Clinical Practice Guidelines – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses the evidenced-based clinical guidelines from nationally recognized sources used to guide our quality and health management programs.
Clinical Trials – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses clinical trials. Applicable Procedure Codes: G0276, G0293, G0294, G2000, S9988, S9990, S9991, S9992, S9994, S9996.
Cochlear Implants – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 04.01.2019 – This policy addresses non-hybrid and hybrid cochlear implantation. Applicable Procedure Codes: 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, V5273.
Cognitive Rehabilitation – UnitedHealthcare West Medical Management Guideline
Last Modified 03.01.2019
Effective Date: 03.01.2019 – This policy addresses cognitive rehabilitation and coma stimulation. Applicable Procedure Codes: 97127, G0515, S9056.
Collagen Crosslinks and Biochemical Markers of Bone Turnover – UnitedHealthcare West Medical Management Guideline
Last Modified 02.01.2019
Effective Date: 02.01.2019 – This policy addresses serum or urine collagen crosslinks or biochemical markers. Applicable Procedure Code: 82523.
Computed Tomographic Colonography – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2018
Effective Date: 12.01.2018 – This policy addresses computed tomographic colonography. Applicable Procedure Codes: 74261, 74262, 74263.
Computer Assisted Surgical Navigation for Musculoskeletal Procedures – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – 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 Procedure Codes: 0054T, 0055T, 0396T, 20985.
Computerized Dynamic Posturography – UnitedHealthcare West Medical Management Guideline
Last Modified 04.01.2019
Effective Date: 04.01.2019 – This policy addresses computerized dynamic posturography (CDP) testing. Applicable Procedure Code: 92548.
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 10.01.2019 – This policy addresses insulin delivery and continuous glucose monitoring (CGM) for diabetes management. Applicable Procedure Codes: 0446T, 0447T, 0448T, 95249, 95250, 95251, A9274, A9276, A9277, A9278, E0784, E1399, K0553, K0554, S1030, S1031, S1034, S1035, S1036, S1037.
Core Decompression for Avascular Necrosis – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses core decompression avascular necrosis . Applicable Procedure Codes: 21299, 23929, 27299, 27599, 27899, S2325.
Corneal Hysteresis and Intraocular Pressure Measurement – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses measurement of corneal hysteresis, measurement of ocular blood flow, and monitoring of intraocular pressure. Applicable Procedure Codes: 0198T, 0329T, 66999, 67299, 92145.
Cosmetic and Reconstructive Procedures – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 08.01.2019 – This policy addresses cosmetic and reconstructive procedures.
Cytological Examination of Breast Fluids for Cancer Screening or Diagnosis – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses breast ductal lavage, breast ductal fluid aspiration and cytology, and fiberoptic ductoscopy with or without ductal lavage. Applicable Procedure Code: 19499.
Deep Brain and Cortical Stimulation – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 01.01.2019 – This policy addresses deep brain and responsive cortical stimulation. Applicable Procedure Codes: 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, 64999, L8679, L8680, L8682, L8685, L8686, L8687, L8688.
Discogenic Pain Treatment – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses thermal intradiscal procedures (TIPs) and percutaneous discectomy and decompression procedures for treating discogenic pain, and annulus fibrosus repair following spinal surgery. Applicable Procedure Codes: 22526, 22527, 22899, 62287, 62380, S2348.
Elbow Replacement Surgery (Arthroplasty) – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses elbow replacement surgery (arthroplasty). Applicable Procedure Codes: 24360, 24361, 24362, 24363, 24370, 24371.
Electric Tumor Treatment Field Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses the use of devices to generate electric tumor treatment fields (TTF). Applicable Procedure Codes: 77299, A4555, E0766.
Electrical and Ultrasound Bone Growth Stimulators – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 08.01.2019 – This policy addresses electrical, electromagnetic, and ultrasonic bone growth stimulators. Applicable Procedure Codes: 20975, 20979, E0747, E0748, E0749, E0760.
Electrical Bioimpedance for Cardiac Output Measurement – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses electrical bioimpedance for cardiac output measurement. Applicable Procedure Code: 93701.
Electrical Stimulation and Electromagnetic Therapy for Wounds – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 02.01.2019 – This policy addresses electrical stimulation and electromagnetic therapy for wounds. Applicable Procedure Codes: E0769, G0281, G0282, G0295, G0329.
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), interferential therapy (IFT), pulsed electrical stimulation (PES), peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS), microcurrent electrical nerve stimulation (MENS), percutaneous electrical nerve stimulation (PENS) or percutaneous neuromodulation therapy (PNT), dorsal root ganglion (DRG) stimulation, and scrambler therapy (ST). Applicable Procedure Codes: 0278T, 63650, 63655, 63685, 64999, E0744, E0745, E0762, E0764, E0770, E1399, L8679, L8680, L8682, L8685, L8686, L8687, L8688, S8130, S8131.
Electroencephalographic (EEG) Monitoring and Video Recording – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses electroencephalographic (EEG) monitoring and video recording. Applicable Procedure Code: 95951.
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome – UnitedHealthcare West Medical Management Guideline
Last Modified 04.01.2019
Effective Date: 04.01.2019 – This policy addresses embolization of the ovarian or internal iliac veins. Applicable Procedure Code: 37241.
Emergency and Urgently Needed Health Care Services – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses emergency health care services, physician-ordered emergency department visits, screening and stabilization of an emergency medical conditions, and post-stabilization care services. Applicable Procedure Codes: 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99281, 99282, 99283, 99284, 99285, 99288, G0378, G0379, G0380, G0381, G0382, G0383, G0384, G0390, S9083, S9088.
Epidural Steroid and Facet Injections for Spinal Pain – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses epidural steroid and facet injections for spinal pain. Applicable Procedure Codes: 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0230T, 0231T, 62322, 62323, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495.
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic Discography – UnitedHealthcare West Medical Management Guideline
Last Modified 11.26.2019
Effective Date: 12.01.2018 – This policy addresses epiduroscopy (including spinal myeloscopy), percutaneous and endoscopic epidural lysis of adhesions, and functional anesthetic discography (FAD) for the diagnosis or treatment of any type of neck or back pain or spinal disorder. Applicable Procedure Codes: 62263, 62264, 64999.
Extracorporeal Shock Wave Therapy (ESWT) – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses extracorporeal shock wave therapy (ESWT). Applicable Procedure Codes: 0101T, 0102T, 0512T, 0513T, 28890.
Fecal Calprotectin Testing – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses fecal measurement of calprotectin. Applicable Procedure Code: 83993.
Femoroacetabular Impingement Syndrome – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses surgical treatment for femoroacetabular impingement (FAI) syndrome. Applicable Procedure Codes: 27299, 29914, 29915, 29916, 29999.
Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 05.01.2019 – This policy addresses DNA-based noninvasive prenatal tests of fetal aneuploidy. Applicable Procedure Codes: 0009M, 0060U, 81420, 81422, 81479, 81507.
Functional Endoscopic Sinus Surgery (FESS) – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Gastrointestinal Motility Disorders, Diagnosis and Treatment – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 05.01.2019 – This policy addresses gastric electrical stimulation therapy, manometry and rectal sensation, tone, and compliance test, defecography, electrogastrography, and electroenterography. Applicable Procedure Codes: 43647, 43648, 43881, 43882, 64590, 64595, 76496, 76498, 91117, 91120, 91122, 91132, 91133.
Gender Dysphoria Treatment Excluding California – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses gender dysphoria treatment, including gender reassignment surgery and certain ancillary procedures.
Genetic Testing for Cardiac Disease – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses genetic testing for cardiac disease. Applicable Procedure Codes: 81410, 81411, 81413, 81414, 81439, 81443, 81493.
Genetic Testing for Hereditary Cancer – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses hereditary breast and ovarian cancer (BRCA1, BRCA2) testing and multi-gene hereditary cancer panel testing.
Genetic Testing for Neuromuscular Disorders – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses multi-gene panel testing for the diagnosis of neuromuscular disorders. Applicable Procedure Codes: 81443, 81440, 81460, 81465, 81479.
Glaucoma Surgical Treatments – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 08.01.2019 – This policy addresses glaucoma drainage devices/stents, canaloplasty, and viscocanalostomy. Applicable Procedure Codes: 0191T, 0253T, 0376T, 0449T, 0450T, 0474T, 66170, 66174, 66175, 66179, 66180, 66183, 66184, L8612.
Gynecomastia Treatment – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses mastectomy or suction lipectomy for the treatment of benign gynecomastia. Applicable Procedure Code: 19300.
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – 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.
Hepatitis Screening – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses hepatitis screening. Applicable Procedure Codes: 81596, 86704, 86705, 86706, 86707, 86708, 86709, 86803, 86804, 87340, 87341, 87350, 87902, 87912, G0472, G0499.
High Frequency Chest Wall Compression Devices – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses high-frequency chest wall compression (HFCWC). Applicable Procedure Codes: A7025, A7026, E0483.
Hip Resurfacing and Replacement Surgery (Arthroplasty) – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses hip resurfacing and replacement surgery (arthroplasty). Applicable Procedure Codes: 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, S2118.
Home Hemodialysis – UnitedHealthcare West Medical Management Guideline
Last Modified 03.01.2019
Effective Date: 03.01.2019 – This policy addresses home hemodialysis (HHD). Applicable Procedure Codes: 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 99512, S9335.
Home Traction Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses home traction therapy. Applicable Procedure Codes: E0830, E0840, E0849, E0850, E0855, E0856, E0860, E0941.
Hysterectomy for Benign Conditions – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses hysterectomy. Applicable Procedure Codes: 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58550, 58552, 58553, 58554.
Immune Globulin – Site of Care – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses hospital outpatient facility infusion services for intravenous immune globulin (IVIG) and subcutaneous immune globulin (SCIG) therapy.
Implantable Beta-Emitting Microspheres for Treatment of Malignant Tumors – UnitedHealthcare West Medical Management Guideline
Last Modified 01.01.2019
Effective Date: 01.01.2019 – This policy addresses transarterial radioembolization (TARE) using yttrium-90 (90Y) microspheres for the treatment of unresectable metastatic liver tumors from primary colorectal cancer (CRC), unresectable metastatic liver tumors from neuroendocrine tumors, unresectable primary hepatocellular carcinoma (HCC), and unresectable intrahepatic cholangiocarcinoma. Applicable Procedure Codes: 37243, 79445, S2095.
Implanted Electrical Stimulator for Spinal Cord – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses implanted electrical stimulator for spinal cord. Applicable Procedure Codes: 63650, 63655, 63685, 63688, C1767, C1778, C1816, C1820, C1822, C1823, C1883, C1897, L8679, L8680, L8682, L8685, L8686, L8687, L8688, L8695.
Inpatient Pediatric Feeding Programs – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses inpatient pediatric feeding programs.
Intensity-Modulated Radiation Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 01.01.2019
Effective Date: 01.01.2019 – This policy addresses the use of intensity-modulated radiation therapy (IMRT). Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Intensive Behavioral Therapy for Autism Spectrum Disorder – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses intensive behavioral therapy for autism spectrum disorder.
Intraoperative Hyperthermic Intraperitoneal Chemotherapy (HIPEC) – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Applicable Procedure Code: 96549.
Intrauterine Fetal Surgery – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses intrauterine fetal surgery. Applicable Procedure Codes: 59072, 59074, 59076, 59897, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411.
Knee Replacement Surgery (Arthroplasty), Total and Partial – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses total and partial knee replacement surgery (arthroplasty). Applicable Procedure Codes: 27445, 27446, 27447, 27486, 27487.
Laser Interstitial Thermal Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 08.01.2019 – This policy addresses laser interstitial thermal therapy. Applicable Procedure Codes: 19499, 20999, 27599, 32999, 53899, 55899, 64999.
Light and Laser Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 08.01.2019 – This policy addresses light and laser therapy, including light phototherapy, photodynamic therapy, intense pulsed light, pulsed dye laser, and laser hair removal. Applicable Procedure Codes: 17106, 17107, 17108, 17380.
Lithotripsy for Salivary Stones – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses extracorporeal shock wave lithotripsy (ESWL) and endoscopic intracorporeal laser lithotripsy for treating salivary stones. Applicable Procedure Code: 42699.
Lower Extremity Vascular Angiography – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 10.01.2019 – This policy addresses lower extremity vascular angiography for evaluating arterial disease of the lower extremity. Applicable Procedure Codes: 75710, 75716.
Macular Degeneration Treatment Procedures – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses implantable miniature telescope (IMT), conjunctival incision with posterior extrascleral placement of a pharmacologic agent, epiretinal radiation therapy, and laser photocoagulation. Applicable Procedure Codes: 0308T, 67036, 67299, 92499.
Magnetic Resonance Spectroscopy (MRS) – UnitedHealthcare West Medical Management Guideline
Last Modified 01.01.2019
Effective Date: 01.01.2019 – This policy addresses magnetic resonance spectroscopy (MRS). Applicable Procedure Code: 76390.
Manipulation Under Anesthesia – UnitedHealthcare West Medical Management Guideline
Last Modified 02.01.2019
Effective Date: 02.01.2019 – This policy addresses manipulation under anesthesia (MUA). Applicable Procedure Codes: 21073, 22505, 25259, 27275, 27860, 23700, 24300, 26340, 27198, 27570, D7830.
Manipulative Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses manipulative therapy. Applicable Procedure Codes: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, S8990.
Mechanical Circulatory Support Device (MCSD) – UnitedHealthcare West Medical Management Guideline
Last Modified 02.01.2019
Effective Date: 02.01.2019 – This policy addresses durable mechanical circulatory support devices. Applicable Procedure Codes: 33975, 33976, 33979, 33981, 33982, 33983.
Mechanical Stretching Devices – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses the use of low-load prolonged-duration stretch devices, static progressive (SP) stretch splint devices, and patient actuated serial stretch (PASS) devices. Applicable Procedure Codes: E1399, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841.
Meniscus Implant and Allograft – UnitedHealthcare West Medical Management Guideline
Last Modified 09.23.2019
Effective Date: 06.01.2019 – This policy addresses meniscus allograft transplantation with human cadaver tissue and collagen meniscus implants. Applicable Procedure Codes: 29868, G0428.
Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses minimally invasive endoscopic procedures and devices for treating gastroesophageal reflux disease (GERD). Applicable Procedure Codes: 43210, 43257, 43284, 43289, 43499, 43999.
Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses molecular oncology testing for cancer indications, including breast cancer, thyroid cancer, hematological cancer, and lung cancer.
Motorized Spinal Traction – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses motorized spinal traction devices. Applicable Procedure Code: S9090.
Negative Pressure Wound Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 06.01.2019 – This policy addresses negative pressure wound therapy. Applicable Procedure Codes: 97605, 97606, 97607, 97608, A6550, A9272, E2402.
Nerve Graft to Restore Erectile Function During Radical Prostatectomy – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses sural or other nerve grafts to restore erectile function during radical prostatectomy. Applicable Procedure Codes: 55899, 64999.
Neurophysiologic Testing and Monitoring – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses nerve conduction studies and other neurophysiological testing.
Neuropsychological Testing Under the Medical Benefit – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses neuropsychological testing and computerized cognitive testing under the medical benefit. Applicable Procedure Codes: 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Obstructive Sleep Apnea Treatment – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 08.01.2019 – This policy addresses nonsurgical and surgical treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 0466T, 0467T, 0468T, 21199, 21206, 21685, 41512, 41530, 41599, 42145, 42299, 64553, 64568, 64569, 64570, E0485, E0486, L8679, L8680, L8686, S2080.
Occipital Neuralgia and Headache Treatment – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 04.01.2019 – This policy addresses occipital neuralgia and headache treatments, including injection of local anesthetics and/or steroids used as occipital nerve blocks, neurostimulation or electrical stimulation, occipital neurectomy, radiofrequency ablation (thermal or pulsed) or denervation, rhizotomy, and surgical nerve decompression. Applicable Procedure Codes: 62281, 63185, 63190, 64405, 64553, 64555, 64568, 64570, 64575, 64590, 64633, 64634, 64722, 64744, 64771, 64999, L8679, L8680, L8685.
Omnibus Codes – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses multiple services/procedures.
Oncology Medication Clinical Coverage – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 11.01.2019 – This policy addresses parameters for coverage of injectable oncology medications. Applicable Procedure Codes: J0640, J0641, J1950, J2353, J2354, J9000-J9999.
Orthognathic (Jaw) Surgery – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 07.01.2019 – This policy addresses orthognathic (jaw) surgery.
Osteochondral Grafting – UnitedHealthcare West Medical Management Guideline
Last Modified 01.01.2019
Effective Date: 01.01.2019 – This policy addresses osteochondral autograft and allograft transplantation and minced articular cartilage repair (allograft or autograft). Applicable Procedure Codes: 27415, 27416, 28446, 29866, 29867.
Otoacoustic Emissions Testing – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses neonatal hearing screening, auditory screening, and diagnostic testing using otoacoustic emissions (OAEs). Applicable Procedure Codes: 92558, 92587, 92588.
Panniculectomy and Body Contouring Procedures – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses panniculectomy, abdominoplasty, lipectomy, repair of diastasis recti, and suction-assisted lipectomy. Applicable Procedure Codes: 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879.
Pectus Deformity Repair – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses surgical repair of pectus excavatum and pectus carinatum. Applicable Procedure Codes: 21740, 21742, 21743.
Pharmacogenetic Testing – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of pharmacogenetic multi-gene panel testing for genetic polymorphisms. Applicable Procedure Codes: 0029U, 0078U, 81479.
Plagiocephaly and Craniosynostosis Treatment – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of cranial orthotic devices for treating infants with plagiocephaly and craniosynostosis. Applicable Procedure Codes: 21175, D5924, L0112, L0113, S1040.
Platelet Derived Growth Factors for Treatment of Wounds – UnitedHealthcare West Medical Management Guideline
Last Modified 03.01.2019
Effective Date: 03.01.2019 – This policy addresses recombinant-human platelet derived growth factors and autologous platelet rich plasma. Applicable Procedure Codes: 0232T, G0460, S0157, S9055.
Pneumatic Compression Devices – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses pneumatic compression devices. Applicable Procedure Codes: A4600, E0650, E0651, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676.
Preimplantation Genetic Testing – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 06.01.2019 – This policy addresses preimplantation genetic testing (PGT). Applicable Procedure Codes: 81228, 81229, 81479.
Preventive Care Services – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses preventive care services.
Prolotherapy for Musculoskeletal Indications – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses prolotherapy for musculoskeletal indications. Applicable Procedure Codes: 0232T, 0481T, M0076.
Propranolol Treatment for Infantile Hemangiomas: Inpatient Protocol – UnitedHealthcare West Medical Management Guideline
Last Modified 05.01.2019
Effective Date: 05.01.2019 – This policy addresses the use of oral propranolol for the treatment of infantile hemangiomas (IH).
Proton Beam Radiation Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 01.01.2019 – This policy addresses proton beam radiation therapy. Applicable Procedure Codes: 77301, 77338, 77385, 77386, 77387, 77520, 77522, 77523, 77525, G6015, G6016, G6017.
Provider Administered Drugs – Site of Care – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses outpatient hospital facility-based intravenous medication infusion, including eculizumab (Soliris®).
Pulmonary Rehabilitation – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses pulmonary rehabilitation. Applicable Procedure Codes: 94669, S9473.
Rhinoplasty and Other Nasal Surgeries – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses lysis intranasal synechia, repair of nasal vestibular stenosis or alar collapse, rhinophyma, rhinoplasty, and septal dermatoplasty. Applicable Procedure Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30560, 30620.
Sensory Integration Therapy and Auditory Integration Training – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses sensory integration therapy and auditory integration training. Applicable Procedure Code: 97533.
Shoulder Replacement Surgery (Arthroplasty) – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses shoulder replacement surgery (arthroplasty and hemiarthroplasty). Applicable Procedure Codes: 23470, 23472, 23473, 23474.
Skilled Care and Custodial Care Services – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses skilled care and custodial care services. Applicable Procedure Codes: 99509, S5100, S5101, S5102, S5105, S5120, S5121, S5125, S5126, S5130, S5131, S5135, S5136, S5140, S5141, S5150, S5151, S5170, S5175, S9125, T1005, T1019, T1020.
Skin and Soft Tissue Substitutes – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses skin and soft tissue substitutes.
Sodium Hyaluronate – UnitedHealthcare West Medical Management Guideline
Last Modified 11.01.2019
Effective Date: 10.01.2019 – This policy addresses intra-articular injections of sodium hyaluronate. Applicable Procedure Codes: 20605, 20606, 20610, 20611, J3490, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Soliris® (Eculizumab) – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses the use of Soliris® (eculizumab). Applicable Procedure Code: J1300.
Spinal Ultrasonography – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses spinal and paraspinal ultrasonography. Applicable Procedure Codes: 76536, 76800, 76856, 76857, 76881, 76882.
Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses varicose vein ablative and stripping procedures and ligation procedures. Applicable Procedure Codes: 36465, 36466, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37780, 37799.
Surgical Treatment for Spine Pain – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses surgical treatment for spine pain.
Temporomandibular Joint Disorders – UnitedHealthcare West Medical Management Guideline
Last Modified 12.04.2019
Effective Date: 04.01.2019 – This policy addresses treatment of temporomandibular joint (TMJ) disorders. Applicable Procedure Codes: 20605, 20606, 21010, 21050, 21060, 21085, 21089, 21110, 21240, 21242, 21243, 29800, 29804, 90901, 97039, 97139, E0746, E1399, E1700, E1701, E1702.
Therapeutic Radiopharmaceuticals – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses the use of therapeutic radiopharmaceuticals, including Azedra® (iobenguane I 131) and Lutathera® (lutetium Lu 177 dotatate) injection for intravenous use, and Xofigo® (radium-223). Applicable Procedure Codes: A9513, A9606, A9699.
Thermography – UnitedHealthcare West Medical Management Guideline
Last Modified 04.01.2019
Effective Date: 04.01.2019 – This policy addresses thermography, including digital infrared thermal imaging, temperature gradient studies, and magnetic resonance (MR) thermography. Applicable Procedure Codes: 76498, 93740.
Total Artificial Disc Replacement for the Spine – UnitedHealthcare West Medical Management Guideline
Last Modified 07.15.2019
Effective Date: 07.01.2019 – This policy addresses cervical and lumbar artificial total disc replacement. Applicable Procedure Codes: 0095T, 0098T, 0163T, 0164T, 0165T, 0375T, 22856, 22857, 22858, 22861, 22862, 22864, 22865.
Total Artificial Heart – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses the SynCardia™ temporary Total Artificial Heart. Applicable Procedure Codes: 33927, 33928.
Transcatheter Heart Valve Procedures – UnitedHealthcare West Medical Management Guideline
Last Modified 02.01.2019
Effective Date: 02.01.2019 – This policy addresses transcatheter heart valve (aortic, pulmonary, mitral, tricuspid) procedures, including valve-in-valve procedures and transcatheter cerebral protection devices. Applicable Procedure Codes: 0345T, 0483T, 0484T, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33999, 93799.
Transcranial Magnetic Stimulation – UnitedHealthcare West Medical Management Guideline
Last Modified 08.16.2019
Effective Date: 02.01.2019 – This policy addresses transcranial magnetic stimulation and navigated transcranial magnetic stimulation (nTMS). Applicable Procedure Codes: 64999, 90867, 90868, 90869.
Transpupillary Thermotherapy – UnitedHealthcare West Medical Management Guideline
Last Modified 06.01.2019
Effective Date: 06.01.2019 – This policy addresses transpupillary thermotherapy. Applicable Procedure Codes: 67299, 92499.
Umbilical Cord Blood Harvesting and Storage for Future Use – UnitedHealthcare West Medical Management Guideline
Last Modified 07.01.2019
Effective Date: 07.01.2019 – This policy addresses collection and storage of umbilical cord blood. Applicable Procedure Codes: 38205, 38206, 38207, 88240, S2140.
Unicondylar Spacer Devices for Treatment of Pain or Disability – UnitedHealthcare West Medical Management Guideline
Last Modified 08.01.2019
Effective Date: 08.01.2019 – This policy addresses unicondylar spacer devices for treating knee joint pain or disability from any cause. Applicable Procedure Code: 27599.
Vagus and External Trigeminal Nerve Stimulation – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses implantable vagus nerve stimulators and transcutaneous (non-implantable) vagus and trigeminal nerve stimulators. Applicable Procedure Codes: 61885, 64553, 64568, 64570, E0770, E1399, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688.
Virtual Upper Gastrointestinal Endoscopy – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses virtual upper gastrointestinal endoscopy. Applicable Procedure Codes: 76497, 76498.
Visual Information Processing Evaluation and Orthoptic and Vision Therapy – UnitedHealthcare West Medical Management Guideline
Last Modified 12.01.2019
Effective Date: 12.01.2019 – This policy addresses occlusion therapy, pharmacologic penalization therapy, orthoptic or vision therapy, prism adaptation therapy, visual perception therapy, vision restoration therapy, and the use of visual information processing evaluations to diagnose reading or learning disabilities. Applicable Procedure Codes: 92065, 92499.
Warming Therapy and Ultrasound Therapy for Wounds – UnitedHealthcare West Medical Management Guideline
Last Modified 10.01.2019
Effective Date: 10.01.2019 – This policy addresses warming therapy, noncontact normothermic wound therapy, and low frequency ultrasound for treating wounds. Applicable Procedure Codes: 97610, A6000, E0221, E0231, E0232.
Whole Exome and Whole Genome Sequencing – UnitedHealthcare West Medical Management Guideline
Last Modified 09.01.2019
Effective Date: 09.01.2019 – This policy addresses whole exome and whole genome sequencing. Applicable Procedure Codes: 0012U, 0013U, 0014U, 0036U, 0094U, 81415, 81416, 81417, 81425, 81426, 81427.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.