UHC Part 1

PENELOPE HEALTH
Effective January 1, 2026
POLICY UPDATE
UnitedHealthcare: January 1, 2026
What changed & What to do.
part 1
Summary
UnitedHealthcare updated their medical policies effective January 1, 2026. The changes require more specific documentation and introduce new coding requirements across cardiovascular, orthopedic, oncology, and other service lines.
This report identifies specific changes that affect claim approvals and reimbursement. Understanding these updates is critical to preventing denials and maintaining revenue cycle efficiency.
Cardiovascular
Complete code deletions and new requirements
Orthopedic
Increased documentation burden
Oncology
Biosimilar switches required
Global Documentation Changes
UnitedHealthcare has fundamentally changed what constitutes complete documentation. These requirements apply across all service lines and represent the foundation for claim approval. Providers must adapt their documentation practices immediately to avoid systematic denials.
1
Condition Requiring Procedure
Previous requirement: Diagnosis
New requirement: Active condition requiring intervention now
A patient may have chronic back pain for 10 years. The condition requiring procedure is the recent functional decline or neurological deficit that failed conservative care. Document the specific triggering event, not just the chronic diagnosis.
2
Onset, Duration, and Frequency
All symptoms must include three specific data points:
Onset: When did it start? 
Duration: How long does each episode last? 
Frequency: How often does it occur?
Example: 
"Frequent palpitations" gets denied.

"Palpitations occurring 3-4 times weekly lasting 2 hours" gets approved.
3
Relevant Recent Imaging
Previous requirement: Complete diagnostic imaging
New requirement: Relevant recent diagnostic imaging
UHC can reject imaging older than 6 months. If your only MRI is 9 months old, get a new one or obtain a physician attestation that clinical status has not changed.
Top Tips for Providers
Document the specific event that triggered the surgical request, not just the chronic diagnosis
Include onset date, episode duration, and weekly/monthly frequency for all symptoms
Order new imaging if existing studies are older than 6 months
Update EHR templates to capture these three specific fields automatically
Cardiovascular Services
Lower Extremity Revascularization: Complete Code Deletion
Critical Change
Old codes 37220-37235 are deleted. Claims using these codes will reject immediately.
New Codes
New codes 37254-37299 (46 codes total) replace the old series.
Effective January 1, 2026, the entire lower extremity revascularization code family has been replaced. This is not a simple code update- it represents a fundamental restructuring of how these procedures are documented and billed.
New Coding Structure
Documentation must specify two critical elements:
1. Vascular Territory
Iliac: 37254-37261
Femoral/Popliteal: 37263-37278
Tibial/Peroneal: 37280-37295
Inframalleolar (below ankle): 37296-37299
2. Lesion Complexity
Straightforward: stenosis
Complex: occlusion or complex anatomy
Documentation Requirements
Surgeons must detail specific characteristics:
Total occlusion vs. stenosis
Heavy calcification
Length of occlusion
Specialized crossing techniques needed
Generic notes like "SFA occlusion revascularization" default to lower-reimbursement codes or trigger queries.
Critical Warning: Inframalleolar Territory
Codes 37296-37299 exist, but atherectomy and stenting in this territory remain unproven per UHC policy. The code exists but coverage does not (except limb salvage in CLTI).
Top Tips for Providers
Document exact vascular territory in operative note
Specify "complex" features: total occlusion, calcification, length, crossing techniques
For inframalleolar interventions, document limb salvage indication explicitly
Update templates to capture territory and complexity as separate structured fields
Patent Foramen Ovale (PFO) Closure
CPT Code: 93580
PFO closure requires extensive exclusionary workup. UHC demands proof that all other stroke causes are ruled out. This is not a simple procedural authorization. Instead, it requires a comprehensive diagnostic investigation documented across multiple specialties.
Required Testing
All tests must be recent:
Carotid ultrasound (rule out carotid disease)
Hypercoagulable panel (rule out clotting disorders)
Extended cardiac monitoring (rule out atrial fibrillation)
If tests are older than 12 months, repeat them or obtain a physician attestation that clinical status has not changed.
Required Consultations
Two separate consult notes required:
Neurology note stating "PFO is likely stroke mechanism"
Cardiology note stating "PFO is likely stroke mechanism"
If the neurology note says "cryptogenic stroke" without explicitly implicating the PFO, the claim is at risk.
01
Complete Fresh Workup
All testing within 12 months of procedure
02
Obtain Specialty Consults
Both neurology and cardiology must explicitly state PFO as stroke mechanism
03
Document Negative Results
Carotid disease, hypercoagulable states, and AFib ruled out
04
Submit Authorization
Include attestation if re-using older tests
Top Tips for Providers
Complete fresh workup within 12 months of procedure
Ensure both neurology and cardiology notes explicitly state PFO as stroke mechanism
Document negative results for carotid disease, hypercoagulable states, and AFib
If re-using older tests, add attestation that clinical status unchanged
Catheter Ablation for Atrial Fibrillation
CPT Codes: 93653, 93656
Pre-operative testing must meet specific freshness requirements. These are not suggestions—they are hard stops that will trigger immediate denials if not met. The financial impact of missing these requirements is substantial given the high reimbursement rates for ablation procedures.
1
Electrolytes
Within 6 months
2
TSH
Within 12 months
3
Stress Test
Within 12 months
$13K
Minimum Reimbursement
CPT 93656 base rate
$20K
Maximum Reimbursement
With complexity factors
$50
TSH Test Cost
That could deny entire claim
CPT 93656 (PVI Ablation) reimburses $13,000-$20,000. A technical denial because a $50 TSH test was out of date represents a catastrophic process failure.
Top Tips for Providers
Update pre-admission testing protocols to flag these specific date requirements
Order new TSH if existing result is older than 12 months
Document electrolytes and stress test dates in authorization packet
Set calendar reminders for test expiration dates
Orthopedic and Spinal Surgery
Spinal Fusion: Two Measurements Required
CPT Codes: 22633, 22612
UnitedHealthcare now requires quantitative proof of conservative care failure. This represents a fundamental shift from narrative documentation to data-driven evidence. The policy explicitly states: "Failure of conservative therapy through lack of clinically significant improvement between at least two measurements, on a validated pain or function scale."
Measurement A
Start of therapy: ODI Score 40%
Conservative Care
6 months PT and injections
Measurement B
End of therapy: ODI Score 38%
Conclusion
Lack of clinically significant improvement
Validated Scales
Oswestry Disability Index (ODI) - Most commonly used for back pain
VAS Pain Scale - Visual analog scale for pain measurement
Claims without two distinct data points are incomplete upon arrival. Previous documentation like "Patient failed 6 months of PT and injections" is no longer sufficient.
Smoking Status
Document "Smoking history/status, including date of last smoking cessation."
Blank field or active use within 6 weeks of surgery triggers denial for non-union risk. This is a hard stop that cannot be appealed without documented cessation.
Top Tips for Providers
Administer ODI or VAS at every visit, record in structured data fields
Capture baseline score before conservative therapy begins
Capture follow-up score after conservative therapy ends
Document specific smoking cessation date (not just "former smoker")
Update EHR templates to require these two measurements before fusion orders
MILD Procedure: Code Exists, Coverage Does Not
Critical Alert
MILD = Minimally Invasive Lumbar Decompression
This is a coverage trap that will catch unprepared providers
Effective January 1, 2026, the MILD procedure experienced a significant coding change that creates a dangerous coverage gap. Understanding this distinction is critical to avoiding claim denials and patient financial liability.
Old Code Deleted
0275T removed from CPT
New Codes Created
62330 (primary level)
62331 (add-on level)
Coverage Status
Unproven and Not Medically Necessary
The CPT code became valid, but coverage did not change. UHC lists 62330 and 62331 as Unproven and Not Medically Necessary for UHC Commercial/Oxford plans.
Action Required
Block codes 62330 and 62331 in claim scrubbers for UHC Commercial/Oxford plans unless Advanced Beneficiary Notice (ABN) is on file.
This prevents automatic claim submission for procedures that will be denied, protecting both the provider and patient from unexpected financial liability.
Top Tips for Providers
Do not assume new CPT code equals coverage
Verify payer policy before scheduling MILD procedures
Obtain ABN from patients if proceeding with non-covered procedure
Consider alternative procedures covered by UHC
Joint Replacement Imaging Requirements
UnitedHealthcare now requires "complete diagnostic interpretation of imaging findings" to include specific grading scales. Generic descriptions are no longer acceptable. This change affects both hip and knee replacement authorizations and represents a significant documentation burden for radiology departments.
Hip (FAI)
Use Tönnis or Outerbridge grading
Document specific cartilage damage grade
Include acetabular and femoral head assessment
Knee
Document Outerbridge grade (I-IV)
Document joint space alignment
Specify compartmental involvement
Insufficient Documentation
"Bone-on-bone"
"Severe tricompartmental OA"
"Advanced degenerative changes"
"End-stage arthritis"
Required Documentation
"Outerbridge Grade IV cartilage loss medial compartment"
"Tönnis Grade 3 osteoarthritis with complete joint space narrowing"
"Outerbridge Grade III-IV tricompartmental disease"
Top Tips for Providers
Request radiologist to include Outerbridge grading in report
Add specific grade to dictation: "Outerbridge Grade IV cartilage loss"
Update radiology order templates to request specific grading scales
Train coding staff to identify missing grades before claim submission
Oncology and Hematology
Soliris (Eculizumab): Mandatory Switch to Biosimilars
Status Change
Soliris is no longer a preferred agent
Preferred Biosimilars
Bkemv (eculizumab-aeeb)
Epysqli (eculizumab-aagh)
This policy change affects both new and existing patients. Members currently receiving Soliris must switch to biosimilars upon reauthorization unless they demonstrate clinical failure or intolerance to biosimilars. This is not optional—it is a mandatory formulary change that will result in denials if not addressed proactively.
Critical Impact
This applies to existing patients. Submitting a renewal for Soliris without documenting biosimilar failure will result in denial and interrupt patient care.
The financial impact is substantial—Soliris costs approximately $500,000 per year per patient. Biosimilars offer equivalent efficacy at reduced cost, which is driving this formulary change.
Action Required
Review Soliris patient roster immediately
Schedule switch to Bkemv or Epysqli before authorization expires
Document biosimilar trial if patient experiences issues
Update infusion center inventory to stock preferred biosimilars
01
Identify Affected Patients
Review all patients currently on Soliris
02
Schedule Biosimilar Switch
Transition to Bkemv or Epysqli before reauthorization
03
Monitor Patient Response
Document any adverse reactions or efficacy concerns
04
Update Protocols
Revise infusion center procedures and inventory
Top Tips for Providers
Identify all patients currently on Soliris
Schedule switch to Bkemv or Epysqli before authorization expires
Document biosimilar trial if patient experiences issues
Update infusion center inventory to stock preferred biosimilars