The Coverage Summaries, corresponding update bulletins, and related Medical Benefit Injectable Policies for UnitedHealthcare Medicare Advantage plans are listed below.
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A monthly notice of recently approved and/or revised UnitedHealthcare Medicare Advantage Coverage Summaries 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 Coverage Summary 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 Coverage Summary Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 07.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 08.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 09.01.2023
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Medicare Advantage Coverage Summaries.
Last Published 09.01.2023
A listing of the Medicare Advantage Coverage Summary Update Bulletins for the past two rolling years.
These policies provide additional information on medical benefit injectables addressed in the UnitedHealthcare Medicare Advantage Coverage Summaries.
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Last Published 07.01.2023
Effective Date: 07.01.2023 - This policy addresses Medicare Part B step therapy programs.
These UnitedHealthcare Coverage Summaries are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
General Statements
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:
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:
Coverage Summaries are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited.
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Last Published 06.01.2023
This policy addresses ambulance transportation by ground or air.
Last Published 07.01.2023
This policy addresses upper and lower eyelid blepharoplasty, brow ptosis repair, upper eyelid blepharoptosis repair, reduction of overcorrection ptosis, ectropion/entropion repair, lid retraction, correction of lagophthalmos, canthoplasty/canthopexy, and floppy eyelid syndrome repair. Applicable Procedure Codes: 15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67912, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950, 67961, 67966.
Last Published 04.15.2023
This policy addresses blood components, clotting factors, platelets, and transfusions, including related products and services.
Last Published 09.01.2023
This policy addresses cardiac pacemakers, pulmonary artery pressure measurements, and ventricular assist devices (VADs). Applicable Procedure Codes: 0345T, 33274, 33275, 33289, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 93264, C2624.
Last Published 08.15.2023
This policy addresses diagnostic and therapeutic procedures. Applicable Procedure Codes: 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 92979, 93050, 93653, 93655, 93656, 93657.
Last Published 09.01.2023
This policy addresses complementary and alternative therapies or services and chiropractic services. Applicable Procedure Codes: 64999, A9270.
Last Published 09.01.2023
This policy addresses cosmetic and reconstructive surgical services. Applicable Procedure Codes: 11920, 11921, 11922, 11960, 15731, 15733, 15734, 15736, 15738, 15756, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 19300, 19316, 19318, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 21235, 21740, 21742, 21743, 28344.
Last Published 08.15.2023
This policy addresses dental services or oral surgery, temporomandibular joint (TMJ), and orthognathic surgery. Applicable Procedure Codes: E0849, E0855, E1700, E1702.
Last Published 08.15.2023
This policy addresses training, equipment, and supplies for the treatment and management of diabetes. Applicable Procedure Codes: 95249, 95250, 95251.
Last Published 09.15.2023
This policy addresses specific durable medical equipment (DME), prosthetics, corrective appliances/orthotics (non-foot orthotics), nutritional therapy, and medical supplies, including repairs, maintenance, and replacement. Applicable Procedure Codes: A4606, A4614, E0118, E0445, E0465, E0466, E0467, E0483.
Last Published 09.01.2023
This policy addresses neuromuscular electrical stimulator (NMES), functional electric stimulators (FES), spinal cord stimulators, dorsal root ganglion (DRG) stimulators, deep brain stimulation for essential tremor and Parkinson’s Disease, implanted peripheral nerve stimulators, transcutaneous electrical nerve stimulator (TENS), electrical osteogenic stimulator, ultrasonic osteogenic stimulator, phrenic nerve stimulators, electrical stimulation for the treatment of motor function disorders and dysphagia, electrotherapy for the treatment of facial nerve paralysis (Bell's palsy), percutaneous electrical nerve stimulation (PENS), and percutaneous neuromodulation therapy (PNT). Applicable Procedure Codes: 63650, E0770, E0764, L8680.
Last Published 11.01.2022
This policy addresses emergency services, urgently-needed services, post-stabilization care services, follow-up care, and ambulance services.
Last Published 07.01.2023
This policy addresses gastroesophageal and gastrointestinal (GI) services, procedures, and related devices. Applicable Procedure Codes: 0184T, 43257, 43284, 43647, 43648, 43881, 43882, 46601, 46607, 64590, 64595, 74261, 74262, 74263, 76497, 76498, 83993, 91110, 91111, 91113.
Last Published 09.01.2023
This policy addresses genetic testing and counseling, including tumor markers, cytogenetic studies, and molecular diagnostic genetic tests.
Last Published 08.01.2023
This policy addresses insertion of aqueous drainage devices, implantation of glaucoma drainage devices, canaloplasty, and viscocanalostomy. Applicable Procedure Codes: 0253T, 0449T, 0450T, 0474T, 66174, 66175, 66183.
Last Published 08.01.2023
This policy addresses hearing services and devices, including hearing screening/examinations, hearing aids, auditory implants, audiology services, and computerized dynamic posturography.
Last Published 09.01.2023
This policy addresses home health, skilled care, and related services and supplies.
Last Published 07.01.2023
This policy addresses inpatient and outpatient hospital services, outpatient observation services and surgical procedures, religious nonmedical health care institutions (RNHCIs), long term care hospitals (LTCH), and never events.
Last Published 08.15.2023
This policy addresses core decompression for avascular necrosis, hip resurfacing arthroplasty (HRA), hip/knee/elbow/shoulder replacement surgery (arthroplasty), unicompartmental knee arthroplasty, surgical treatment for femoroacetabular impingement (FAI) syndrome, and arthroscopic lavage and debridement for osteoarthritis of the knee. Applicable Procedure Codes: 21299, 23470, 23472, 23473, 23474, 23929, 24360, 24361, 24362, 24363, 27120, 27122, 27130, 27132, 27134, 27137, 27138, 27299, 27445, 27446, 27447, 27486, 27487, 27599, 27899, 29914, 29915, 29916, S2325.
Last Published 09.01.2023
This policy addresses laboratory tests and services (inpatient or outpatient). Applicable Procedure Code: 82306.
Last Published 09.01.2023
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.
Last Published 08.15.2023
This policy addresses septoplasty, rhinoplasty, vestibular stenosis repair, balloon sinus ostial dilation, and functional endoscopic sinus surgery (FESS). Applicable Procedure Codes: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 31299.
Last Published 09.01.2023
This policy addresses neurologic services and procedures, neurophysiological studies and neuropsychological testing, including but not limited to surgical procedures, cranial treatments, and seizure treatments.
Last Published 09.01.2023
This policy addresses non-surgical services (intensive behavioral therapy for obesity), surgical treatment (bariatric surgery), second bariatric surgeries, and examples of non-covered services.
Last Published 09.01.2023
This policy addresses kidney, kidney-pancreas, pancreas transplants, stem cell transplantation and bone marrow transplantation, islet cell transplantation in the context of a clinical trial, immunosuppressive drugs, and transplant-related services.
Last Published 07.01.2023
This policy addresses collagen and non-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).
Last Published 09.01.2023
This policy addresses pain management, inpatient and outpatient pain rehabilitation programs, and related services. Applicable Procedure Codes: 20526, 20550, 20551, 20612, 27096, 28899, 62263, 62264, 62287, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64405, 64451, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64625, 64633, 64634, 64635, 64636, 64722, 64744, G0260.
Last Published 09.01.2023
This policy addresses services and procedures for the diagnosis and treatment of prostate conditions and related impotence treatment. Applicable Codes: 53855, 52441, 52442, 55874, C9739, C9740, L8699.
Last Published 08.15.2023
This policy addresses high-dose rate electronic brachytherapy, implantable beta-emitting microspheres for treatment of malignant tumors, 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), local hyperthermia, computer-assisted surgical navigation for musculoskeletal procedures, tumor treatment field therapy (TTFT), and magnetic resonance image guided high intensity focused ultrasound (MRgFUS). Applicable Procedure Codes: 0394T, 0395T, 0398T, 20985, 37243, 77014, 77331, 77371, 77372, 77373, 77385, 77386, 77387, 77402, 77407, 77412, 77470, 77520, 77522, 77523, 77524, 77525, 79445, A4555, E0766, G0339, G0340, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017.
Last Published 09.01.2023
This policy addresses diagnostic radiological services (inpatient and outpatient).
Last Published 09.01.2023
This policy addresses cardiac rehabilitation (CR) exercise programs, supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) , outpatient rehabilitation therapy (physical and occupational therapy and speech-language pathology services), inpatient rehabilitation services, cognitive therapy, melodic intonation therapy, passive rehabilitation therapy for mandibular hypomobility, comprehensive computer-based motion analysis, and rehabilitation services for vision impairment. Applicable Procedure Codes: 93668, 97024, 97035.
Last Published 09.01.2023
This policy addresses infertility tests and treatments, family planning, and maternity care services.
Last Published 09.01.2023
This policy addresses pulmonary rehabilitation services and home use of oxygen. Applicable Procedure Codes: 31660, 31661.
Last Published 09.01.2023
This policy addresses diagnosis and treatment of obstructive sleep apnea (OSA). Applicable Procedure Codes: 41530, 64569, 64570, 64582, 64583, 64584, 95800, 95801, 95806, G0398, G0399, G0400.
Last Published 09.01.2023
This policy addresses lumbar spinal fusion, ciervical spinal fusion, allograft or synthetic bone graft materials, spinal decompression, interspinous process decompression, interlaminar lumbar instrumented fusion (ILIF), arthrodesis, intra-facet implants, percutaneous decompression procedures, percutaneous image-guided lumbar decompresson (PILD), percutaneous vertebroplasty and vertebral augmentation, stereotactic computer assisted volumetric and/or navigational procedures, percutaneous minimally invasive fusion, and lumbar artificial disc. Applicable Procedure Codes: 0095T, 0098T, 0165T, 0200T, 0201T, 0219T, 0220T, 0221T, 0222T, 20930, 20931, 20932, 20933, 20934, 22510, 22511, 22512, 22513, 22514, 22515, 22586, 27279, 22856, 22857, 22858, 22860, 22861, 22862, 22864, 22867, 22868, 22869, 22870, 22899, 62287.
Last Published 09.15.2023
This policy addresses diagnosis, treatments, and devices for urinary and fecal incontinence. Applicable Codes: K1006, L8605.
Last Published 07.01.2023
This policy addresses uterine artery embolization, magnetic resonance imaging (MRI)-guided focused ultrasound ablation, hysterectomy, and use of intrauterine devices (IUD) for treatment of endometrial hyperplasia. Applicable Procedure Codes: 0071T, 0072T, 37243, 58999.
Last Published 08.15.2023
This policy addresses treatment of varicose veins in lower extremities, including ligation and excision (stripping), endovenous radiofrequency ablation or endovenous laser ablation, sclerotherapy, endomechanical ablation of incompetent extremity veins, and embolization of the ovarian and iliac veins for pelvic congestion syndrome. Applicable Procedure Codes: 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37241, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785.
Last Published 09.01.2023
This policy addresses vision services, including examinations, testing, surgical procedures, therapy, and rehabilitation. Applicable Procedure Codes: 0100T, 0308T, 76514, 92025, 92065, 92132, 92133, 92134, 92227, 92228, 92250, C1840.
Last Published 09.15.2023
This policy addresses wound and ulcer treatments, including skin substitutes, electrical stimulation (ES) or electromagnetic therapy, topical application of oxygen, and noncontact normothermic wound therapy.
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.
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.