Why UHC Denies Shoulder Arthroscopy / Rotator Cuff Repair
Conservative therapy not exhausted (PT, injections)
Partial tear does not meet surgical threshold
Imaging does not correlate with symptoms
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 tear size and location on MRI
Show failure of 3-6 months PT and at least one subacromial injection
Note functional limitations and pain severity
Reference full-thickness tear or significant partial tear (>50%)
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 Rotator Cuff
- AIM Specialty Health Shoulder Surgery Guidelines
Relevant CPT Codes
Specialty: Orthopedics
Want the full strategy?
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