24363
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
21.45
Facility
$1300.63
Non-Facility
$1300.63
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews.
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan.
- Before using this policy, check the member specific benefit plan document and any applicable federal or state mandates.
Key Coverage Criteria
- Surgery of the elbow when proven and medically necessary in circumstances that meet clinical coverage criteria
- Arthroscopy, Diagnostic, +/- Synovial Biopsy, Elbow when it meets InterQual® CP criteria
- Arthroscopy, Surgical, Elbow when it meets InterQual® CP criteria
- Joint Replacement, Elbow when it meets InterQual® CP criteria
- Removal or Revision, Arthroplasty, Elbow when it meets InterQual® CP criteria
3 Active Policies
UHC-POL-surgery-elbow — Surgery of the Elbow
UMR-POL-UMR-surgery-elbow — Surgery of the Elbow
SUREST-POL-SUREST-surgery-elbow — Surgery of the Elbow
Related Codes
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