Protocol: ORT014 Effective Date: August 1, 2015 ELBOW REPLACEMENT SURGERY (ARTHROPLASTY) Table of Contents Page COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE... 1 U.S. FOOD AND DRUG ADMINISTRATION (FDA)... 2 APPLICABLE CODES... 3 PROTOCOL HISTORY/REVISION INFORMATION... 13 INSTRUCTIONS FOR USE This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute medical advice. UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us in administering health benefits. The MCG Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE For information regarding medical necessity review, when applicable, see MCG Care Guidelines, 19th edition, 2015, Elbow Arthroplasty, S-420 (ISC), Accessed June 2015. Clinical Indications are listed below: Elbow Arthroplasty, S-420 (ISC) Clinical Indications for Procedure Procedure is indicated for 1 or more of the following: 1. Rheumatoid arthritis treatment indicated by ALL of the following: Failure of alternative treatments (eg, pharmacotherapy, cortisone injections, synovectomy) Pain or loss of function resulting in inability to perform activities of daily living 2. Inability to perform activities of daily living due to 1 or more of the following: Ankylosis of the elbow or other advanced disease causing loss of function Elbow Replacement Surgery (Arthroplasty) Page 1 of 13
Posttraumatic arthrosis causing pain or loss of function Supracondylar causing loss of function 3. Joint instability from tumor resection or other destructive process 4. Hemophilic arthropathy 5. Comminuted distal humerus fracture and ALL of the following: Patient older than 65 years of age Patient with osteopenia 6. Complex fracture of radial head 7. Elbow dislocation with fracture of the radial head and coronoid process ("terrible triad fracture") 8. Displaced intra-articular distal humerus fracture and 1 or more of the following: Osteoporosis Fracture not amenable to internal fixation 9. Revision of failed elbow arthroplasty *** End of MCG Medicare does not have a National Coverage Determination (NCD) for Elbow Replacement. Local Coverage Determinations (LCDs) do not exist at this time. (Accessed June 2015) For Medicare and Medicaid Determinations Related to States Outside of Nevada: Please review Local Coverage Determinations that apply to other states outside of Nevada. http://www.cms.hhs.gov/mcd/search Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage database on the Centers for Medicare and Medicaid Services Website. U.S. FOOD AND DRUG ADMINISTRATION (FDA) Elbow replacement surgery is a procedure and therefore is not regulated by the FDA. However, devices and instruments used during the surgery require FDA approval. See the following website for additional information (product codes JDC and KWI): http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm Accessed June 2015. FDA-approved total or partial elbow replacement surgery devices are generally approved for the same indications, including any or all of the following: Non-inflammatory degenerative joint disease such as osteoarthritis Rheumatoid arthritis Post-traumatic arthritis, tumor or bone loss causing elbow instability Complex fracture(s) of elbow components Ankylosis Revision of failed elbow replacement surgery Correction of functional deformity Elbow Replacement Surgery (Arthroplasty) Page 2 of 13
APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document. This list of codes may not be all inclusive. CPT Codes 24360 Arthroplasty, elbow; with membrane (e.g., fascial) 24361 Arthroplasty, elbow; with distal humeral prosthetic replacement 24362 Arthroplasty, elbow; with implant and fascia lata ligament reconstruction 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total elbow 24370 Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component 24371 Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component CPT is a registered trademark of the American Medical Association ICD-9 Procedure Codes 81.84 Total Elbow Replacement ICD-9 Diagnosis Codes 170.4 Malignant neoplasm of bone and articular cartilage; Scapula and long bones of upper limb 714.0 Rheumatoid arthritis 714.30 Polyarticular juvenile rheumatoid arthritis, chronic or unspecified 714.89 Other specified inflammatory polyarthropathies 715.12 Primary localized osteoarthrosis, upper arm 715.22 Secondary localized osteoarthrosis, upper arm 715.32 715.92 Localized osteoarthrosis not specified whether primary or secondary, upper arm Osteoarthrosis, unspecified whether generalized or localized, upper arm 716.12 Traumatic arthropathy, upper arm 718.52 Ankylosis of upper arm joint 718.82 Other joint derangement, not elsewhere classified, upper arm 732.3 Juvenile osteochondrosis of upper extremity 733.82 Nonunion of fracture ICD-10 Codes (Preview Draft) In preparation for the transition from ICD-9 to ICD-10 medical coding on October 1, 2015*, a sample listing of the ICD-10 CM and/or ICD-10 PCS codes associated with this policy has been provided below for your reference. This list of codes may not be all inclusive and will be updated to reflect any Elbow Replacement Surgery (Arthroplasty) Page 3 of 13
applicable revisions to the ICD-10 code set and/or clinical guidelines outlined in this policy. *The effective date for ICD-10 code set implementation is subject to change. ICD-10 Diagnosis M06.821 Other specified rheumatoid arthritis, right elbow M06.822 Other specified rheumatoid arthritis, left elbow M06.829 Other specified rheumatoid arthritis, unspecified elbow M08.021 Unspecified juvenile rheumatoid arthritis, right elbow M08.022 Unspecified juvenile rheumatoid arthritis, left elbow M08.029 Unspecified juvenile rheumatoid arthritis, unspecified elbow M08.221 Juvenile rheumatoid arthritis with systemic onset, right elbow M08.222 Juvenile rheumatoid arthritis with systemic onset, left elbow M08.229 Juvenile rheumatoid arthritis with systemic onset, unspecified elbow M08.821 Other juvenile arthritis, right elbow M08.822 Other juvenile arthritis, left elbow M08.829 Other juvenile arthritis, unspecified elbow M08.921 Juvenile arthritis, unspecified, right elbow M08.922 Juvenile arthritis, unspecified, left elbow M08.929 Juvenile arthritis, unspecified, unspecified elbow M12.521 Traumatic arthropathy, right elbow M12.522 Traumatic arthropathy, left elbow M12.529 Traumatic arthropathy, unspecified elbow M19.021 Primary osteoarthritis, right elbow M19.022 Primary osteoarthritis, left elbow M19.029 Primary osteoarthritis, unspecified elbow M19.121 Post-traumatic osteoarthritis, right elbow M19.122 Post-traumatic osteoarthritis, left elbow M19.129 Post-traumatic osteoarthritis, unspecified elbow M19.221 Secondary osteoarthritis, right elbow M19.222 Secondary osteoarthritis, left elbow M19.229 Secondary osteoarthritis, unspecified elbow M24.621 Ankylosis, right elbow M24.622 Ankylosis, left elbow M24.629 Ankylosis, unspecified elbow M24.821 Other specific joint derangements of right elbow, not elsewhere classified M24.822 Other specific joint derangements of left elbow, not elsewhere classified M24.829 Other specific joint derangements of unspecified elbow, not elsewhere classified M25.221 Flail joint, right elbow M25.222 Flail joint, left elbow M25.229 Flail joint, unspecified elbow M25.321 Other instability, right elbow M25.322 Other instability, left elbow Elbow Replacement Surgery (Arthroplasty) Page 4 of 13
M25.329 Other instability, unspecified elbow M80.021K Age-related osteoporosis with current pathological fracture, right humerus, M80.022K Age-related osteoporosis with current pathological fracture, left humerus, M80.029K Age-related osteoporosis with current pathological fracture, unspecified humerus, M80.821K Other osteoporosis with current pathological fracture, right humerus, M80.822K Other osteoporosis with current pathological fracture, left humerus, M80.829K Other osteoporosis with current pathological fracture, unspecified humerus, M84.321K Stress fracture, right humerus, subsequent encounter for fracture with M84.322K Stress fracture, left humerus, subsequent encounter for fracture with M84.329K Stress fracture, unspecified humerus, subsequent encounter for fracture with M84.421K Pathological fracture, right humerus, subsequent encounter for fracture with M84.422K Pathological fracture, left humerus, subsequent encounter for fracture with M84.429K Pathological fracture, unspecified humerus, subsequent encounter for fracture with M84.521K Pathological fracture in neoplastic disease, right humerus, subsequent M84.522K Pathological fracture in neoplastic disease, left humerus, subsequent M84.529K Pathological fracture in neoplastic disease, unspecified humerus, subsequent M84.621K Pathological fracture in other disease, right humerus, subsequent encounter for fracture with M84.622K Pathological fracture in other disease, left humerus, subsequent encounter for fracture with M84.629K Pathological fracture in other disease, unspecified humerus, subsequent M92.00 Juvenile osteochondrosis of humerus, unspecified arm M92.01 Juvenile osteochondrosis of humerus, right arm M92.02 Juvenile osteochondrosis of humerus, left arm S42.441K Displaced fracture (avulsion) of medial epicondyle of right humerus, S42.442K Displaced fracture (avulsion) of medial epicondyle of left humerus, Elbow Replacement Surgery (Arthroplasty) Page 5 of 13
S42.443K S42.444K S42.445K S42.446K S42.447K S42.448K S42.449K S42.451A S42.452A S42.453A S42.454A S42.455A S42.456A S42.461B S42.461K S42.462K S42.463K S42.464K S42.465K S42.466K S42.471K Displaced fracture (avulsion) of medial epicondyle of unspecified humerus, Nondisplaced fracture (avulsion) of medial epicondyle of right humerus, Nondisplaced fracture (avulsion) of medial epicondyle of left humerus, Nondisplaced fracture (avulsion) of medial epicondyle of unspecified humerus, Incarcerated fracture (avulsion) of medial epicondyle of right humerus, Incarcerated fracture (avulsion) of medial epicondyle of left humerus, Incarcerated fracture (avulsion) of medial epicondyle of unspecified humerus, Displaced fracture of lateral condyle of right humerus, initial encounter for closed fracture Displaced fracture of lateral condyle of left humerus, initial encounter for closed fracture Displaced fracture of lateral condyle of unspecified humerus, initial encounter for closed fracture Nondisplaced fracture of lateral condyle of right humerus, initial encounter for closed fracture Nondisplaced fracture of lateral condyle of left humerus, initial encounter for closed fracture Nondisplaced fracture of lateral condyle of unspecified humerus, initial encounter for closed fracture Displaced fracture of medial condyle of right humerus, initial encounter for open fracture Displaced fracture of medial condyle of right humerus, subsequent encounter for fracture with Displaced fracture of medial condyle of left humerus, subsequent encounter for fracture with Displaced fracture of medial condyle of unspecified humerus, subsequent Nondisplaced fracture of medial condyle of right humerus, subsequent Nondisplaced fracture of medial condyle of left humerus, subsequent Nondisplaced fracture of medial condyle of unspecified humerus, subsequent Displaced transcondylar fracture of right humerus, subsequent encounter for fracture with Elbow Replacement Surgery (Arthroplasty) Page 6 of 13
S42.472K S42.473K S42.474K S42.475K S42.476K S42.481K S42.482K S42.489K S42.491K S42.492K S42.493K S42.494K S42.495K S42.496K S49.101K S49.102K S49.109K S49.111A S49.111K S49.112K S49.119K S49.121K Displaced transcondylar fracture of left humerus, subsequent encounter for fracture with Displaced transcondylar fracture of unspecified humerus, subsequent Nondisplaced transcondylar fracture of right humerus, subsequent encounter for fracture with Nondisplaced transcondylar fracture of left humerus, subsequent encounter for fracture with Nondisplaced transcondylar fracture of unspecified humerus, subsequent Torus fracture of lower end of right humerus, subsequent encounter for fracture with Torus fracture of lower end of left humerus, subsequent encounter for fracture with Torus fracture of lower end of unspecified humerus, subsequent encounter for fracture with Other displaced fracture of lower end of right humerus, subsequent encounter for fracture with Other displaced fracture of lower end of left humerus, subsequent Other displaced fracture of lower end of unspecified humerus, subsequent Other nondisplaced fracture of lower end of right humerus, subsequent Other nondisplaced fracture of lower end of left humerus, subsequent Other nondisplaced fracture of lower end of unspecified humerus, subsequent Unspecified physeal fracture of lower end of humerus, right arm, subsequent Unspecified physeal fracture of lower end of humerus, left arm, subsequent Unspecified physeal fracture of lower end of humerus, unspecified arm, Salter-Harris Type I physeal fracture of lower end of humerus, right arm, initial encounter for closed fracture Salter-Harris Type I physeal fracture of lower end of humerus, right arm, Salter-Harris Type I physeal fracture of lower end of humerus, left arm, Salter-Harris Type I physeal fracture of lower end of humerus, unspecified arm, Salter-Harris Type II physeal fracture of lower end of humerus, right arm, Elbow Replacement Surgery (Arthroplasty) Page 7 of 13
S49.122K S49.129K S49.131K S49.132K S49.139K S49.141K S49.142K S49.149K S49.191K S49.192K S49.199K S52.019K S52.021K S52.021M S52.021N S52.022K S52.022M S52.022N S52.023K S52.023M Salter-Harris Type II physeal fracture of lower end of humerus, left arm, Salter-Harris Type II physeal fracture of lower end of humerus, unspecified arm, Salter Harris Type III physeal fracture of lower end of humerus, right arm, Salter Harris Type III physeal fracture of lower end of humerus, left arm, Salter Harris Type III physeal fracture of lower end of humerus, unspecified arm, Salter-Harris Type IV physeal fracture of lower end of humerus, right arm, Salter-Harris Type IV physeal fracture of lower end of humerus, left arm, Salter-Harris Type IV physeal fracture of lower end of humerus, unspecified arm, Other physeal fracture of lower end of humerus, right arm, subsequent Other physeal fracture of lower end of humerus, left arm, subsequent Other physeal fracture of lower end of humerus, unspecified arm, subsequent Torus fracture of upper end of unspecified ulna, subsequent encounter for fracture with right ulna, subsequent encounter for closed fracture with right ulna, subsequent encounter for open fracture type I or II with right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with left ulna, subsequent encounter for closed fracture with left ulna, subsequent encounter for open fracture type I or II with left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with unspecified ulna, subsequent encounter for closed fracture with unspecified ulna, subsequent encounter for open fracture type I or II with Elbow Replacement Surgery (Arthroplasty) Page 8 of 13
S52.023N S52.024A S52.024K S52.024M S52.024N S52.025A S52.025K S52.025M S52.025N S52.026A S52.026K S52.026M S52.026N S52.031A S52.031K S52.031M S52.031N S52.032A unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with of right ulna, initial encounter for closed fracture of right ulna, subsequent encounter for closed fracture with of right ulna, subsequent encounter for open fracture type I or II with of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with of left ulna, initial encounter for closed fracture of left ulna, subsequent encounter for closed fracture with of left ulna, subsequent encounter for open fracture type I or II with of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with of unspecified ulna, initial encounter for closed fracture of unspecified ulna, subsequent encounter for closed fracture with of unspecified ulna, subsequent encounter for open fracture type I or II with of unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of olecranon process with intraarticular extension of right ulna, initial encounter for closed fracture Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for closed fracture with Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open fracture type I or II with Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of olecranon process with intraarticular extension of left Elbow Replacement Surgery (Arthroplasty) Page 9 of 13
S52.032K S52.032M S52.032N S52.033A S52.033K S52.033M S52.033N S52.034A S52.034K S52.034M S52.034N S52.035A S52.035K S52.035M S52.035N S52.036A S52.036K S52.036M ulna, initial encounter for closed fracture Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for closed fracture with Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open fracture type I or II with Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of olecranon process with intraarticular extension of unspecified ulna, initial encounter for closed fracture Displaced fracture of olecranon process with intraarticular extension of unspecified ulna, subsequent encounter for closed fracture with Displaced fracture of olecranon process with intraarticular extension of unspecified ulna, subsequent encounter for open fracture type I or II with Displaced fracture of olecranon process with intraarticular extension of unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with right ulna, initial encounter for closed fracture right ulna, subsequent encounter for closed fracture with right ulna, subsequent encounter for open fracture type I or II with right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with left ulna, initial encounter for closed fracture left ulna, subsequent encounter for closed fracture with left ulna, subsequent encounter for open fracture type I or II with left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with unspecified ulna, initial encounter for closed fracture unspecified ulna, subsequent encounter for closed fracture with unspecified ulna, subsequent encounter for open fracture type I or II with Elbow Replacement Surgery (Arthroplasty) Page 10 of 13
S52.036N S52.041K S52.041M S52.041N S52.042K S52.042M S52.042N S52.043K S52.043M S52.043N S52.044K S52.044M S52.044N S52.045B S52.045C S52.045K S52.045M S52.045N S52.046K S52.046M S52.046N unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of coronoid process of right ulna, subsequent encounter for closed fracture with Displaced fracture of coronoid process of right ulna, subsequent encounter for open fracture type I or II with Displaced fracture of coronoid process of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of coronoid process of left ulna, subsequent encounter for closed fracture with Displaced fracture of coronoid process of left ulna, subsequent encounter for open fracture type I or II with Displaced fracture of coronoid process of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of coronoid process of unspecified ulna, subsequent encounter for closed fracture with Displaced fracture of coronoid process of unspecified ulna, subsequent encounter for open fracture type I or II with Displaced fracture of coronoid process of unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for closed fracture with Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for open fracture type I or II with Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of coronoid process of left ulna, initial encounter for open fracture type I or II Nondisplaced fracture of coronoid process of left ulna, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for closed fracture with Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for open fracture type I or II with Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of coronoid process of unspecified ulna, subsequent encounter for closed fracture with Nondisplaced fracture of coronoid process of unspecified ulna, subsequent encounter for open fracture type I or II with Nondisplaced fracture of coronoid process of unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Elbow Replacement Surgery (Arthroplasty) Page 11 of 13
S52.121K S52.121M S52.121N S52.122C S52.122K S52.122M S52.122N S52.123K S52.123M S52.123N S52.124K S52.124M S52.124N S52.125K S52.125M S52.125N S52.126K S52.126M S52.126N S52.271K S52.271M S52.271N Displaced fracture of head of right radius, subsequent encounter for closed fracture with Displaced fracture of head of right radius, subsequent encounter for open fracture type I or II with Displaced fracture of head of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of head of left radius, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced fracture of head of left radius, subsequent encounter for closed fracture with Displaced fracture of head of left radius, subsequent encounter for open fracture type I or II with Displaced fracture of head of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of head of unspecified radius, subsequent encounter for closed fracture with Displaced fracture of head of unspecified radius, subsequent encounter for open fracture type I or II with Displaced fracture of head of unspecified radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of head of right radius, subsequent encounter for closed fracture with Nondisplaced fracture of head of right radius, subsequent encounter for open fracture type I or II with Nondisplaced fracture of head of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of head of left radius, subsequent encounter for closed fracture with Nondisplaced fracture of head of left radius, subsequent encounter for open fracture type I or II with Nondisplaced fracture of head of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of head of unspecified radius, subsequent encounter for closed fracture with Nondisplaced fracture of head of unspecified radius, subsequent encounter for open fracture type I or II with Nondisplaced fracture of head of unspecified radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Monteggia's fracture of right ulna, subsequent encounter for closed fracture with Monteggia's fracture of right ulna, subsequent encounter for open fracture type I or II with Monteggia's fracture of right ulna, subsequent encounter for open fracture Elbow Replacement Surgery (Arthroplasty) Page 12 of 13
S52.272K S52.272M S52.272N S52.279K S52.279M S52.279N 0RRL 0RRL07Z 0RRL0JZ 0RRL0KZ 0RRM 0RRM07Z 0RRM0JZ 0RRM0KZ type IIIA, IIIB, or IIIC with Monteggia's fracture of left ulna, subsequent encounter for closed fracture with Monteggia's fracture of left ulna, subsequent encounter for open fracture type I or II with Monteggia's fracture of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Monteggia's fracture of unspecified ulna, subsequent encounter for closed fracture with Monteggia's fracture of unspecified ulna, subsequent encounter for open fracture type I or II with Monteggia's fracture of unspecified ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Replacement / Elbow Joint, Right Replacement of Right Elbow Joint with Autologous Tissue Substitute, Open Approach Replacement of Right Elbow Joint with Synthetic Substitute, Open Approach Replacement of Right Elbow Joint with Nonautologous Tissue Substitute, Open Replacement / Elbow Joint, Left Replacement of Left Elbow Joint with Autologous Tissue Substitute, Open Approach Replacement of Left Elbow Joint with Synthetic Substitute, Open Approach Replacement of Left Elbow Joint with Nonautologous Tissue Substitute, Open Approach PROTOCOL HISTORY/REVISION INFORMATION Date 06/25/2015 09/25/2014 04/24/2014 04/25/2013 02/28/2013 04/26/2012 02/23/2012 Action/ Corporate Medical Affairs Committee The foregoing Health Plan of Nevada/Sierra Health & Life Health Operations protocol has been adopted from an existing UnitedHealthcare coverage determination guideline that was researched, developed and approved by the UnitedHealthcare Coverage Determination Committee. Elbow Replacement Surgery (Arthroplasty) Page 13 of 13