UnitedHealthcare Medicare Advantage Coverage Summaries

Please read the terms and conditions below carefully.

These UnitedHealthcare Coverage Summaries are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.

General Statements

• Covered benefits, limitations, and exclusions are specified in the member's applicable UnitedHealthcare Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB).
• All services rendered must be referred and authorized by the member's provider, unless specifically stated otherwise in the EOC or SOB.
• In the absence of an NCD, UnitedHealthcare abides by applicable Local Coverage Determinations (LCDs). LCDs are specific written policies made by the Medicare Administrative Contractor (MAC) with jurisdiction for each individual State. In cases where services are covered by UnitedHealthcare in an area that includes jurisdictions of more than one contractor for original Medicare, and the contractors have different medical review policies, UnitedHealthcare must apply the medical review policies of the contractor in the area where the beneficiary lives.

In the absence of an applicable NCD, LCD, or other CMS published guidance, UnitedHealthcare develops and maintains clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services ("UnitedHealthcare Medical Policies"). Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. These policies are based on current evidence in widely used treatment guidelines or clinical literature. Current, 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. Acceptable 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.

The Coverage Summaries are policies based on existing current Medicare National Coverage Determinations, Local Coverage Determinations, UnitedHealthcare Medical Policies, and applicable UnitedHealthcare Medicare Advantage Plans EOCs and SOBs intended to provide benefit coverage information and guidelines specific to UnitedHealthcare Medicare Advantage Plans. Benefit interpretations for UnitedHealthcare Medicare Advantage Plan members are made on a case-by-case basis using the guidelines in the Coverage Summaries. The Coverage Summaries 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 and in the event that there is a conflict between the Coverage Summaries and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will govern.

Covered benefits, limitations and exclusions are specified in the UnitedHealthcare Medicare Advantage Plan Evidence of Coverage (EOC) and Summary of Benefits (SOB). If there are any differences between the member's UnitedHealthcare Medicare Advantage Plan EOC or SOB and the Coverage Summaries, the member's UnitedHealthcare Medicare Advantage Plan EOC or SOB shall govern. Nothing in the Coverage Summaries is intended to be construed as an expansion of benefits beyond the benefits specified in the UnitedHealthcare Medicare Advantage Plan EOC or SOB or as a basis for payment of any benefits under the UnitedHealthcare Medicare Advantage Plans.

Nothing in the Coverage Summaries is intended to be construed as establishing any guidelines for the practice of medicine or a standard of care for the practice of medicine. UnitedHealthcare does not practice medicine and does not make medical decisions for UnitedHealthcare Medicare Advantage Plan Members. Medical decisions for UnitedHealthcare Medicare Advantage Plan Members are made by the treating physician in conjunction with the member.

The information contained within the Coverage Summaries is strictly proprietary to UnitedHealthcare. The information is not to be copied in whole or part; nor is the information to be distributed without express written consent of UnitedHealthcare.

The Coverage Summaries are based upon:

1. Medicare publications relating to coverage determinations;
2. Laws and regulations which may be applicable to UnitedHealthcare Medicare Advantage Plans; and
3. Research, studies, and evidence from other sources including, but not limited to, the U.S. Food and Drug Administration (FDA).

Many of the benefit interpretations in the Coverage Summaries require a determination of medical necessity to establish coverage. Medical necessity determinations must be made by trained and/or licensed professional medical personnel only.

UnitedHealthcare Medicare Advantage Plan members have the right to appeal benefit decisions in accordance with Medicare guidelines as outlined in the UnitedHealthcare Medicare Advantage Plans EOC or SOB. Any questions regarding appeals should be directed to the UnitedHealthcare Medicare Advantage Plans Appeals Department identified on the members' identification card.

Hierarchy of References/Resources

The Coverage Summaries are developed and written using the following references/resources:

1. National Coverage Determination (NCD) or other Medicare guidance, e.g., Medicare Policy Benefit Manual, Medicare Managed Care Manual, Medicare Claims Processing Manual, Medicare Learning Network (MLN) Matters Articles
2. Local Coverage Determinations (LCDs) and Local Policy Articles (A/B MAC & DME MAC)
3. UnitedHealthcare Medical Policies/Coverage Determination Guidelines

Coverage Summaries are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited.

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