Why UHC Denies Total Hip Replacement
Conservative management not exhausted
BMI exceeds payer threshold (often >40)
Imaging does not show severe joint disease
Know UnitedHealthcare's Criteria
UHC uses InterQual criteria and their own Clinical UM Guidelines (CG series). Medical directors are typically accessible for P2P within 5 business days.
Key policies to know:
- Requires eviCore for MSK and advanced imaging prior auth
- Clinical UM Guidelines (CG series) are publicly available online
- Prior auth through Optum/UHG portal
- Known for strict step therapy requirements on biologics
Building Your Medical Necessity Argument
Document Kellgren-Lawrence grade on imaging
Show failure of NSAIDs, PT, injections, activity modification
Note functional limitations using validated outcome measures
Address BMI and optimization if applicable
P2P Call Tips for UHC
Reference UHC's own Clinical UM Guideline number (e.g., CG-SURG-71)
UHC medical directors respond well to InterQual criteria language
Be specific about which InterQual subset applies
Have the CG policy number ready -- shows you've done your homework
Guidelines to Reference
- AAOS Clinical Practice Guidelines for Hip OA
- MCG Criteria for Total Joint Replacement
Relevant CPT Codes
Specialty: Orthopedics
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