UM Guidelines
Orthopedic

Listed by Conditions


Acromioplasty and Rotator Cuff Repair

Ankle Dislocation, Closed or Open Reduction

Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)

Ankle: Achilles Tendon Repair

Bone Excision

Cervical Fusion, Anterior

Chiropractic Manipulation

Elbow Fracture, Open Treatment

Elbow Arthroplasty

Femur Fracture, Removal of Internal Fixation Device

Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF)

Hip Arthroplasty

Hip Resurfacing

Humerus Fracture, Closed or Open Reduction

Knee Arthroplasty

Knee Arthrotomy

Knee Dislocation, Closed or Open Reduction

Knee: Patella Reconstruction or Realignment for Recurrent Dislocation

Lumbar Diskectomy, Foraminotomy, or Laminotomy

Lumbar Laminectomy

Occupational Therapy

Orthognathic Surgery - Medical Policy

Radius/Ulna Fracture, Closed or Open Reduction

Shoulder Arthroplasty

Slipped Upper Femoral Epiphysis, Closed Reduction

Tibia/Fibula Shaft Fracture, Closed or Open Reduction

Tibial Osteotomy, Adult

Vertebroplasty and Kyphoplasty

Wrist Arthroplasty