The Benefit Interpretation Policies and corresponding update bulletins for UnitedHealthcare West are listed below.
For California members, note that the materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
A monthly notice of recently approved and/or revised Benefit Interpretation Policies (BIPs) is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a health service (e.g., test, drug, device or procedure) in the Benefit Interpretation Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information provided in the Benefit Interpretation Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
Last Published 09.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Benefit Interpretation Policies.
Last Published 10.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Benefit Interpretation Policies.
Last Published 11.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare West Benefit Interpretation Policies.
Last Published 11.01.2024
A listing of the Benefit Interpretation Policy Update Bulletins for the past two rolling years.
UnitedHealthcare has developed Benefit Interpretation Policies to assist us in administering health benefits. These policies are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Benefit coverage for health services is determined by the member specific benefit plan document, such as an Evidence of Coverage or Schedule of Benefits, the Employer's Group Subscriber Agreement, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies.
Our Benefit Interpretation Policies are based upon: (1) federal and/or state laws and regulations which may be applicable to UnitedHealthcare® West; and (2) research, studies, and evidence from other sources (including, but not limited to, the Food and Drug Administration). Benefit Interpretation Policies assist healthcare providers in making coverage determinations, but do not replace an individualized case-by- case review and medical necessity determination for each UnitedHealthcare® West member. All services rendered must be medically necessary as determined by the member's provider. All services rendered must be referred and authorized by the member's provider (unless specifically stated in the member specific benefit plan documents).
For California members, note that the materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
Benefit Interpretation Policies are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis.
Benefit Interpretation Policies are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. Health Plan coverage is provided by or through UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas, Inc., and UnitedHealthcare of Washington, Inc.
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Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses termination of pregnancy, spontaneous abortions, and selective fetal reductions.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses termination of pregnancy, spontaneous abortions, and selective fetal reductions.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses inpatient and outpatient acquired brain injury rehabilitation services, in-home acquired brain injury care, biofeedback, cognitive behavior therapy, coma stimulations, and cognitive rehabilitation under custodial care.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses allergy testing, treatment, and supplies, including allergy serum injections.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses allergy testing, treatment, and supplies, including allergy serum injections.
Last Published 08.01.2024
Effective 08.01.2024 – This policy addresses ambulance transportation by ground or air.
Last Published 08.01.2024
Effective 08.01.2024 – This policy addresses ambulance transportation by ground or air.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses attention deficit hyperactivity disorder (ADHD) medical management, consultation and evaluation services, treatment of underlying coexistent medical conditions, behavior modification, and family counseling.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses attention deficit hyperactivity disorder (ADHD) medical management, consultation and evaluation services, treatment of underlying coexistent medical conditions, behavior modification, and family counseling.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses behavioral health treatment for autism spectrum disorder.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses and autism spectrum disorder, including assessment, coordination of care, referral for consultation/evaluation, medical services, speech/occupational/physical therapy, and therapies, educational services, and behavioral services for autism spectrum disorder.
Last Published 10.01.2024
Effective 10.01.2024 – This policy addresses biofeedback for bladder rehabilitation.
Last Published 10.01.2024
Effective 10.01.2024 – This policy addresses biofeedback for bladder rehabilitation, migraine headaches, and acquired brain injury.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses blood and blood products, blood clotting factors, and blood-associated costs.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses blood and blood products, blood clotting factors, and blood-associated costs.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses cardiac pacemakers, cardiac pacemaker monitoring, implantable automatic defibrillators, and automatic external defibrillators.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses cardiac pacemakers, cardiac pacemaker monitoring, implantable automatic defibrillators, and automatic external defibrillators.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses outpatient cardiac rehabilitation services.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses outpatient cardiac rehabilitation services.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses inpatient and outpatient chemical dependency/substance abuse detoxification services and methadone maintenance.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses inpatient and outpatient chemical dependency/substance abuse detoxification services and methadone maintenance.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses chemical dependency/substance abuse rehabilitation.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses chemical dependency/substance abuse rehabilitation.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses chemotherapy, immunotherapy, and hormonal agents, injectable drugs, infusion therapy, oral drugs, and related oncology services.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses chemotherapy, immunotherapy, and hormonal agents, injectable drugs, infusion therapy, oral drugs, and related oncology services.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses state mandates pertaining to clinical trials.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses state mandates pertaining to clinical trials.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses outpatient and inpatient cognitive rehabilitation therapy and habilitative services.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses outpatient and inpatient cognitive rehabilitation therapy.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses complementary and alternative medicine, including acupuncture, chiropractic care, and massage therapy.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses complementary and alternative medicine, including acupuncture, acupressure, chiropractic care, massage therapy, and neuropath.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses continuity of care conditions and continuing care with a terminated provider for members.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses continuity of care and continuing care with a terminated provider for members.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses cosmetic, reconstructive, and plastic surgical procedures.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses cosmetic, reconstructive, and plastic surgical procedures.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses cosmetic, reconstructive, and plastic surgical procedures.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses cosmetic, reconstructive, and plastic surgical procedures.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses cosmetic, reconstructive, and plastic surgical procedures.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses court, attorney, or agency requested services, including emergency and urgently needed services.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses court, attorney, or agency requested services, including emergency and urgently needed services.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses dental care services and oral surgery.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses dental care services and oral surgery.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses services for the treatment of developmental delay and learning disabilities. This policy applies to members with diagnosed or suspected developmental delay, either global or limited to a specific developmental area.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses services for the treatment of developmental delay and learning disabilities. This policy applies to members with diagnosed or suspected developmental delay, either global or limited to a specific developmental area.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses diabetic management and treatment, including outpatient diabetic self-management training, diabetic supplies and equipment, continuous subcutaneous insulin infusion pump (CSII) and related supplies, visual aids, pen delivery systems, test strips, diabetic tablets, and insulin syringes.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses diabetic management and treatment, including outpatient diabetic self-management training, diabetic supplies and equipment, continuous subcutaneous insulin infusion pump (CSII) and related supplies, visual aids, pen delivery systems, test strips, diabetic tablets, and insulin syringes.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses inpatient and outpatient diagnostic and therapeutic radiological services, including standard X-rays and specialized scanning, imaging and other specialized procedures.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses inpatient and outpatient diagnostic and therapeutic radiological services, including standard X-rays and specialized scanning, imaging and other specialized procedures.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses acute and chronic dialysis (peritoneal or hemodialysis) services and supplies.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses acute/sudden and chronic long term dialysis (peritoneal or hemodialysis) services.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses specific durable medical equipment (DME), prosthetics, corrective appliances/orthotics (non-foot orthotics), and medical supplies.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses specific durable medical equipment (DME), prosthetics, corrective appliances/orthotics (non-foot orthotics), and medical supplies.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses durable medical equipment (DME), prosthetics, corrective appliances/orthotics (non-foot orthotics), and medical supplies.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses durable medical equipment (DME), prosthetics, corrective appliances/orthotics (non-foot orthotics), and medical supplies.
Last Published 07.01.2024
Effective 05.01.2024 – This policy addresses member education programs, nutritional counseling, and health education services.
Last Published 07.01.2024
Effective 05.01.2024 – This policy addresses member education programs, nutritional counseling, and health education services.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses emergency services and urgently needed services.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses emergency services and urgently needed services.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses experimental and/or investigational procedures, items, treatments, studies, tests, drugs, and equipment.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses experimental and/or investigational procedures, items, treatments, studies, tests, drugs, and equipment.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses birth control and contraception methods.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses birth control and contraception methods.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses infertility services.
Last Published 09.03.2024
Effective 09.01.2024 – This policy addresses infertility services.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses routine foot care, foot examination, and other podiatry services.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses routine foot care, foot examination, and other podiatry services.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses surgical and non-surgical treatment for gender dysphoria.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses gender dysphoria (gender identity disorder) treatment.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses gender dysphoria (gender identity disorder) treatment.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses genetic testing and counseling.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses genetic testing and counseling.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses outpatient habilitative services, including physical therapy, occupational therapy, post-cochlear implant aural therapy, cognitive habilitative therapy, manipulative treatment, and speech therapy.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses outpatient habilitative services, including physical therapy, occupational therapy, post-cochlear implant aural therapy, cognitive habilitative therapy, manipulative treatment, and speech therapy.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses hearing screening services, hearing examinations, audiologist diagnostic testing and evaluation, cochlear implant, and hearing aids.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses hearing screening services, hearing examinations, audiologist diagnostic testing and evaluation, cochlear implant, and hearing aids.
Last Published 10.01.2024
Effective 10.01.2024 – This policy addresses home health care visits and related services.
Last Published 10.01.2024
Effective 10.01.2024 – This policy addresses home health care visits and related services.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses hospice and respite care.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses hospice and respite care.
Last Published 09.03.2024
Effective Date: 09.01.2024 – This policy addresses outpatient and acute inpatient hospital services and supplies.
Last Published 09.03.2024
Effective Date: 09.01.2024 – This policy addresses outpatient and acute inpatient hospital services and supplies.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses vaccinations/immunizations.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses vaccinations/immunizations.
Last Published 08.01.2024
Effective 08.01.2024 – This policy addresses inpatient and outpatient mental health services.
Last Published 08.01.2024
Effective 08.01.2024 – This policy addresses inpatient and outpatient mental health services.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses prenatal and postnatal care, inpatient maternity care, and newborn care.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses prenatal and postnatal care, inpatient maternity care, and newborn care.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses medically necessary interventions.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses medically necessary interventions.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses injectable drugs, off-label drug use, tobacco cessation medications, and outpatient drugs and prescription medications.
Last Published 08.01.2024
Effective 08.01.2024 – This policy addresses injectable drugs, off-label drug use, tobacco cessation programs/medications, human growth hormone, and outpatient drugs and prescription medications.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses member-initiated second and third medical opinions.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses member-initiated second and third medical opinions.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses pain management for long term and sudden pain.
Last Published 11.01.2024
Effective 11.01.2024 – This policy addresses pain management for long term and acute pain.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses pervasive developmental disorders and autism spectrum disorder, including assessment, testing, coordination of care, referral for consultation/evaluation, therapies, treatment programs, and prescription drugs.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses pervasive developmental disorders and autism spectrum disorder, including assessment, coordination of care, applied behavioral analysis, behavior training/management/modification, speech/occupational/physical therapy, medications/supplements, and routine laboratory testing.
Last Published 02.01.2024
Effective 02.01.2024 – This policy addresses pervasive developmental disorders and autism spectrum disorder, including assessment, coordination of care, referral for consultation/evaluation, medically necessary neuro-developmental therapies, speech/occupational/physical therapy, and applied behavioral analysis.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses physician care (primary care physician, provider and specialist) diagnostic, consultation, and treatment services and referred specialist services.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses physician care (primary care physician, provider and specialist) diagnostic, consultation, and treatment services and referred specialist services.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses post mastectomy surgery.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses post mastectomy surgery.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses preventive health care services.
Last Published 01.01.2024
Effective 01.01.2024 – This policy addresses preventive health care services.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses rehabilitation services, including acute inpatient rehabilitation, outpatient physical and occupational therapy, and speech therapy.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses rehabilitation services, including acute inpatient rehabilitation, outpatient physical and occupational therapy, and speech therapy.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses services received while confined/incarcerated, or, if a juvenile, while detained in any facility.
Last Published 12.01.2023
Effective 12.01.2023 – This policy addresses services received while confined/incarcerated, or, if a juvenile, while detained in any facility.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses services or costs associated with a non-covered service.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses services or costs associated with a non-covered service.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses diagnostic services, medications/drugs, procedures, services, and supplies for the treatment of sexual dysfunction or inadequacy.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses diagnostic services, medications/drugs, procedures, services, and supplies for the treatment of sexual dysfunction or inadequacy.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses specialized footwear, shoes, and foot orthotics.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses specialized footwear, shoes, and foot orthotics.
Last Published 03.01.2024
Effective 03.01.2024 – This policy addresses skilled nursing facility (SNF) care.
Last Published 03.01.2024
Effective 03.01.2024 – This policy addresses skilled nursing facility (SNF) care.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses telemedicine/telehealth services and virtual visits.
Last Published 07.01.2024
Effective 07.01.2024 – This policy addresses telemedicine/telehealth services and virtual visits.
Last Published 10.01.2024
Effective 08.01.2024 – This policy addresses human organ and tissue transplants, donor-related services (including organ acquisition), pre-transplant testing and evaluation/examination, bone marrow and stem cell transplants, and transplant related costs and services.
Last Published 10.01.2024
Effective 08.01.2024 – This policy addresses human organ and tissue transplants, donor-related services (including organ acquisition), pre-transplant testing and evaluation/examination, bone marrow and stem cell transplants, and transplant related costs and services.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses surgical and non-surgical treatments and related services for extreme obesity.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses surgical and non-surgical treatments and related services for extreme obesity.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses treatment for temporomandibular joint (TMJ) disorders.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses treatment for temporomandibular joint (TMJ) disorders.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses Veteran's Administration (VA) services, including emergency/urgent care services, skilled nursing facility (SNF) care, out-of-area services, and non-emergent services.
Last Published 04.01.2024
Effective 04.01.2024 – This policy addresses Veteran's Administration (VA) services, including emergency/urgent care services, skilled nursing facility (SNF) care, out-of-area services, and non-emergent services.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses vision care and services, including eye exams, eyeglasses, contact lenses, intraocular lenses (IOLs), surgical and laser procedures, and visual aids.
Last Published 06.01.2024
Effective 06.01.2024 – This policy addresses vision care and services, including eye examinations, eyeglasses, contact lenses, intraocular lenses (IOLs), surgical and laser procedures, and visual aids.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses weight gain and weight loss programs, prescription drugs to treat obesity, and enhancement medications.
Last Published 05.01.2024
Effective 05.01.2024 – This policy addresses weight gain and weight loss programs and prescription drugs to treat obesity.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.