Once in a Lifetime Procedures Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

The Once in a Lifetime Procedures Policy identifies procedures that because of the Current Procedural Terminology (CPT®) code description and/or human anatomy can be performed by a physician(s) or otherqualifiedhealth care professional(s) only once in a patient’s lifetime.

Policy Codes

Find your specific codes below.

This policy contains more codes than can be displayed on one screen. Find your specific code below.

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  • 30160
  • 31360
  • 31365
  • 32440
  • 32442
  • 32445
  • 38100
  • 38102
  • 41140
  • 41145
  • 42140
  • 43620
  • 43621
  • 43622
  • 44150
  • 44151
  • 44155
  • 44156
  • 44157
  • 44158
  • 44210
  • 44211
  • 44212
  • 44950
  • 44955
  • 44960
  • 44970
  • 45110
  • 45112
  • 45119
  • 45120
  • 45121
  • 45126
  • 45395
  • 45397
  • 47562
  • 47563
  • 47564
  • 47600
  • 47605
  • 47610
  • 47612
  • 47620
  • 48155
  • 49250
  • 51570
  • 51575
  • 51580
  • 51585
  • 51590
  • 51595
  • 51596
  • 51597
  • 51925
  • 52649
  • 53210
  • 53215
  • 54125
  • 54130
  • 54135
  • 54150
  • 54160
  • 54161
  • 54861
  • 55801
  • 55810
  • 55812
  • 55815
  • 55821
  • 55831
  • 55840
  • 55842
  • 55845
  • 55866
  • 56625
  • 56633
  • 56634
  • 56637
  • 57110
  • 57111
  • 57112
  • 57530
  • 57531
  • 57540
  • 57545
  • 57550
  • 57555
  • 57556
  • 58150
  • 58152
  • 58180
  • 58200
  • 58210
  • 58240
  • 58260
  • 58262
  • 58263
  • 58267
  • 58270
  • 58275
  • 58280
  • 58285
  • 58290
  • 58291
  • 58292
  • 58293
  • 58294
  • 58541
  • 58542
  • 58543
  • 58544
  • 58548
  • 58550
  • 58552
  • 58553
  • 58554
  • 58570
  • 58571
  • 58572
  • 58573
  • 58575
  • 58950
  • 58951
  • 58952
  • 58953
  • 58954
  • 58956
  • 59135
  • 60240
  • 60252
  • 60254
  • 60270
  • 60271
* COMM-Once-In-a-Lifetime-Procedures-Policy.pdf
Click to Download: Once in a Lifetime Procedures Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions and Answers

Q: Would there ever be an instance where aCPT code for aOnce in a Lifetime Proceduremay be reported more than once?

A: Yes, there are instances where a CPT code for a Once in a Lifetime Proceduremay be reported more than once.  Modifiers may be used to indicate a procedure or service has been altered in some way, but not changed in its actual code description.  For example, by definition, modifier 53 (Discontinued Procedure) is to be used when a procedure is terminated for unforeseeable circumstances.  Per coding guidelines, the procedure code would be initially reported with modifier 53 appended to the CPT code to indicate the discontinued procedure and then at a later time, the CPT code would be submitted again when (if) the procedure took place in its entirety.    

Q: How is a Once in a Lifetime Procedurereimbursed when reported by two different physicians on different dates of service?

A: When any physician or otherqualifiedhealth care professional reports a code from the Once in a Lifetime Procedure policy list on multiple dates of service excluding the same date of service, the code will be reimbursed only once.  UnitedHealthcare follows a "first in, first out" claim payment methodology in determining which claim will be considered for reimbursement when duplicate claims are received.

Q: What if two different physicians each report the same procedure on the same date of service for the same patient from the Once in a Lifetime Procedures list?

A:  The Once in a Lifetime Procedure codes are subject to duplicate billing logic when reported by the same or different providers.