Musculoskeletal procedures update

Effective Feb. 1, 2024, UPMC Health Plan will begin requiring prior authorizations for certain musculoskeletal procedures, which will be evaluated using corresponding Interqual Connect criteria. Those procedures, and the associated procedure codes, are:

• Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes
  • CPT codes: 28285, 28286
• Arthroscopy or Arthroscopically Assisted Surgery, Wrist
  • CPT codes: 25628, 25685, 25695, 29843, 29844, 29845, 29846, 29847
• Arthroscopy, Surgical, Ankle
  • CPT codes: 29891, 29892, 29894, 29895, 29897, 29898, 29904, 29905, 29906, 29907
• Arthrotomy, Wrist
  • CPT codes: 25040, 25101, 25105, 25107, 25115, 25118, 25119, 25608, 25609, 25645, 25670, 25676
• Osteotomy, Distal Transpositional, First Metatarsal (MT) (Bunionectomy)
  • CPT codes: 28296, 28299
• Osteotomy, Proximal, First Metatarsal (MT) (Bunionectomy)
  • CPT codes: 28295, 28297, 28298
• Plantar Fascial Release
  • CPT codes: 28008, 28060, 28062, 28250, 29893
• Reduction and Fixation, Radius +/- Ulna Shaft
  • CPT codes: 25500, 25505, 25515, 25520, 25525, 25526, 25530, 25545, 25560, 25565, 25574, 25575

Authorization coding documentation is available at upmchp.us/PriorAuth as well as the auth entry/inquiry page on Provider OnLine. If you have any questions or concerns about this matter, please contact your physician account executive or call Provider Services at 1-866-918-1595.

Providers are responsible for appropriate billing of services. These suggested codes are not meant to provide or supersede clinical judgment. An authorization is not a guarantee of payment for services rendered.