UnitedHealthcare Implements Medical Necessity Reviews for Some Musculoskeletal Procedures

UnitedHealthcare is implementing medical necessity reviews for certain musculoskeletal surgeries rendered in an outpatient hospital (including of the elbow, wrist, ankle, hip, knee, or shoulder, as well as foot surgeries for bunions and hammertoes). The outpatient hospital site will be determined to be medically necessary if certain criteria are met.

If the outpatient hospital site of service is determined not to be medically necessary, the claim will be denied and the member is responsible for the cost of the service as long as the hospital obtained the member’s written consent to be billed in accordance with UHC’s protocols, prior to the service being rendered.

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