Medicare Advantage Policy Guidelines Terms and Conditions
Please read the terms and conditions below carefully
The Medicare Advantage Policy Guidelines are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
UnitedHealthcare has developed Medicare Advantage Policy Guidelines to assist us in administering health benefits. These Policy Guidelines 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 Policy Guidelines.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines to comply with changes in Centers for Medicare & Medicaid Services (CMS) policy. UnitedHealthcare encourages physicians and other healthcare professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or regulatory changes directly from CMS and/or your local carrier. UnitedHealthcare's Medicare Advantage Policy Guidelines do not include notations regarding prior authorization requirements. View a list of services that are subject to notification/prior authorization requirements. Medicare Advantage Policy Guidelines may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.
Medicare Advantage Policy 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. UnitedHealthcare may modify these Policy Guidelines at any time by publishing a new version of the policy on this website. The information presented in the Medicare Advantage Policy Guidelines is believed to be accurate and current as of the date of publication. Medicare Advantage Policy Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited.
You are responsible for submission of accurate claims. Medicare Advantage Policy Guidelines are intended to ensure that coverage decisions are made accurately based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Medicare Advantage Policy Guidelines use Current Procedural Terminology (CPT®**), CMS, or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement or guarantee claims payment.
*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.
**CPT® is a registered trademark of the American Medical Association.
By clicking "I Agree," you agree to be bound by the terms and conditions expressed herein, in addition to our Site Use Agreement.
The Policy Guidelines and corresponding update bulletins for UnitedHealthcare Medicare Advantage plans are listed below.
A monthly notice of recently approved and/or revised UnitedHealthcare Medicare Advantage Policy Guidelines 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 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 Medicare Advantage Policy Guideline Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
This policy addresses coronary fractional flow reserve using computed tomography (FFR-CT) for the evaluation of coronary artery disease (CAD), including the HeartFlow® FFRct technology. Applicable Procedure Codes: 0501T, 0502T, 0503T, and 0504T.
This policy addresses computerized dynamic posturography (CDP) for the treatment of neurologic disease and inherited disorders, peripheral vestibular disorders, and disequilibrium in the aging/elderly. Applicable Procedure Code: 92548.
This policy addresses Tier 2 molecular pathology procedures, which are procedures not identified by Tier 1 molecular pathology procedures or other CPT codes. Applicable Procedure Codes: 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408.
This policy addresses transcutaneous electrical nerve stimulation (TENS) for the relief of acute post-operative pain, chronic pain other than low back pain and chronic low back pain. Applicable Procedure Codes: A4556, A4557, A4558, A4595, A4630, E0720, E0730, E0731.
This policy addresses transportation services, including emergency ambulance services (ground), non-emergency (scheduled) ambulance service (ground), emergency air ambulance transportation, and ambulance service to a physician's office.
This policy addresses the use of Xofigo® (radium Ra 223 dichloride) injection for the treatment of castration-resistant prostate cancer (CRPC), symptomatic bone metastases, and no known visceral metastatic disease. Applicable Procedure Codes: 79101, A9606.