25441
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
12.96
Facility
$869.09
Non-Facility
$869.09
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; 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, please check the member specific benefit plan document and any applicable federal or state mandates.
Key Coverage Criteria
- Surgery of the hand or wrist is proven and medically necessary in certain circumstances.
- Arthroplasty, Carpometacarpal (CMC) Joint, Thumb (per InterQual® CP: Procedures).
- Arthroplasty, Metacarpophalangeal (MCP) Joint, Digits (per InterQual® CP: Procedures).
- Arthroplasty, Proximal Interphalangeal (PIP) Joint, Fingers (per InterQual® CP: Procedures).
- Arthroscopy or Arthroscopically Assisted Surgery, Wrist (per InterQual® CP: Procedures).
- Arthroscopy, Diagnostic, +/- Synovial Biopsy, Wrist (per InterQual® CP: Procedures).
3 Active Policies
UHC-POL-surgery-hand-wrist — Surgery of the Hand or Wrist
UMR-POL-UMR-surgery-hand-wrist — Surgery of the Hand or Wrist
SUREST-POL-SUREST-surgery-hand-wrist — Surgery of the Hand or Wrist
Related Codes
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