Musculoskeletal procedures update
Dec. 2023Important Notices
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:
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.
- 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.
Recent Announcements
Pause in Prior Authorization Policies
On April 1, 2025, we announced that UPMC Health Plan would start requiring prior authorization for certain services. Please note that we are delaying or changing the implementation of prior authorization for some of these services, as described below.May 2025Important Notices
May is Mental Health Awareness Month
“Turn Awareness into Action”Mental Health America founded Mental Health Month in 1949, and since that time, every May has been a time to unite millions of people to promote awareness, provide vital resources, and advocate for everyones mental well-being. 1 in 5 people will experience a mental health condition in any given year¹. Mental health affects us all, and its critical that we move beyond awareness to take meaningful steps for our well-being and that of our community.May 2025Important Notices
Special notice: Important policy changes
Effective June 1, 2025, UPMC Health Plan will be implementing policy changes that will require providers to obtain prior authorizations for services listed in the following policies. For more information, please visit upmchp.us/policiesandprocedures.May 2025Important Notices