Cosmetic and Reconstructive Procedures
Microtia repair is reconstructive; although no Functional Impairment may be documented for Microtia, this has been deemed Reconstructive Surgery. Related Commercial Policies • Blepharoplasty, Blepharoptosis and Brow Ptosis Repair • Breast Reconstruction Post Mastectomy and Poland Syndrome •
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Coverage Summary - UHCprovider.com Home
www.uhcprovider.comThe benefit information in this Coverage Summary is based on existing national coverage ... Also see the Medicare Prescription Drug Benefit Manual,Chapter 6, ...
UnitedHealthcare Group Medicare Advantage …
www.uhcprovider.comUnitedHealthcare® Group Medicare Advantage (PPO) Plan Network Care Provider Quick Reference Guide Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
Shoulder Replacement Surgery (Arthroplasty)
www.uhcprovider.comShoulder Replacement Surgery (Arthroplasty) ... FDA-approved reverse shoulder replacement surgery devices are generally approved for gross rotator cuff deficiency. The patient's joint must be anatomically and structurally suited to receive the selected implant(s), and a functional
NEUROMUSCULAR ELECTRICAL STIMULATION …
www.uhcprovider.comNeuromuscular Electrical Stimulation (NMES) (NCD 160.12) Page 2 of 3 UnitedHealthcare Medicare Advantage Policy Guideline Approved 08/09/2017
APREPITANT FOR CHEMOTHERAPY-INDUCED …
www.uhcprovider.comChemotherapy-induced nausea and vomiting (CINV) can range from mild to severe, with the most severe cases resulting in dehydration, malnutrition, metabolic imbalances, and potential withdrawal from future chemotherapy
Clinical Performance Guideline Medical Fertility Solutions ...
www.uhcprovider.comClinical Performance Guideline Fertility Solutions Infertility Medical Necessity Guideline Purpose: To provide an understanding of infertility treatment, issues surrounding infertility surgery, and issues surrounding multiple embryo transfers among individuals faced with the potential loss of fertility.
EXTRACORPOREAL SHOCK WAVE TREATMENT (ESWT)
www.uhcprovider.comExtracorporeal Shock Wave Treatment (ESWT) Page 1 of 4 ... Extracorporeal shock wave therapy (ESWT), using either a high- or low-dose protocol or a radial wave, is considered not medically necessary for all indications, including but not limited to the treatment of:
Pervasive Developmental Disorder and Autism Spectrum …
www.uhcprovider.comPervasive Developmental Disorder and Autism Spectrum Disorder: Benefit Interpretation Policy (Effective 01/01/2018) 3 Proprietary Information of UnitedHealthcare.
Pervasive Developmental Disorder and Autism Spectrum …
www.uhcprovider.compervasive developmental disorders include autism, Rett's disorder, childhood disintegrative disorder, Asperger's disorder, and unspecified pervasive developmental disorder. E. …
Approval Date: October 10, 2018 - UHCprovider.com Home
www.uhcprovider.comRetinal Prosthesis Page 1 of 3 UnitedHealthcare Medicare Advantage Policy Guideline Approved 10/10/2018 Proprietary Information of UnitedHealthcare.
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www.harvardpilgrim.orgRepair of Pectus Excavatum Repair of Pectus Carinatum Repair of Chest Wall Deformity for Poland Syndrome Breast Implant Removal and/or Revision Breast Reconstruction Eye Procedures Brow Ptosis Repair Lower Blepharoplasty Upper Blepharoplasty Upper Blepharoptosis Repair Nasal Procedures Rhinophyma Treatment Rhinoplasty Septoplasty …
Services that require precertification
www.ibxtpa.com• Repair or replacement of all DME items that require precertification • Speech generating devices Medical foods Hyperbaric oxygen therapy Sleep studies (facility based) Transplants All transplant procedures, with the exception of corneal transplants Mental health/serious mental illness/substance abuse1
Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair
www.uhcprovider.comUpper eyelid blepharoptosis repair (CPT 67901–67909) is considered reconstructive and medically necessary when the following criteria are present: The member must have a Functional or Physical Impairment complaint directly related to the position of the eyelid(s); and Other treatable causes of ptosis are ruled out (e.g., recent Botox ®