UnitedHealthcare Coverage Overview
UnitedHealthcare (UHC) is the largest private health insurer in the United States. For knee osteoarthritis patients, the good news is that UHC lists hyaluronic acid injections as “proven and medically necessary” in their medical policy—meaning coverage is available when criteria are met.
However, coverage details vary significantly by plan type, so understanding your specific benefits is essential.
Quick Coverage Summary
| Treatment | Coverage Status | Prior Auth Required |
|---|---|---|
| Hyaluronic acid (gel shots) | Covered with criteria | Usually yes |
| Cortisone injections | Covered | Usually no |
| Physical therapy | Covered | Usually no |
| PRP injections | Not covered | N/A |
| Stem cell injections | Not covered | N/A |
UHC’s Position on Hyaluronic Acid
Official Medical Policy
UnitedHealthcare’s medical policy states that sodium hyaluronate (HA) injections are “proven and medically necessary” for the treatment of knee osteoarthritis when specific criteria are met.[1]
Coverage Criteria:
What “Proven and Medically Necessary” Means
This classification is stronger than many insurers provide. It indicates:
- UHC acknowledges clinical evidence supports HA
- Coverage is policy-based, not subject to case-by-case review (when criteria met)
- Denials are less common than with insurers who call HA “experimental”
Prior Authorization Requirements
What to Expect
Most UHC plans require prior authorization for HA injections. This means:
- Your provider submits a request before treatment
- UHC reviews the request against medical policy
- Approval is issued (or denied with reason)
- Treatment proceeds once approved
Prior Auth Process
Includes diagnosis, imaging, treatment history, and medical necessity statement
Typically 1-5 business days for standard requests
Approval, denial, or request for additional information
Once approved, proceed with injection
Tips for Smooth Approval
Plan Variations
Employer-Sponsored Plans
Coverage varies by employer. Some employers:
- Include HA without restrictions
- Require step therapy (try cortisone first)
- Have higher or lower copays
- May exclude HA altogether (check your SPD)
Individual/ACA Marketplace Plans
Coverage depends on the specific plan level and benefits. Generally:
- Silver and Gold plans more likely to cover
- Prior authorization typically required
- In-network providers strongly preferred
Medicare Advantage (UHC branded)
UHC Medicare Advantage plans typically follow Medicare coverage rules:
- HA covered under Part B equivalent
- Prior authorization may or may not apply
- Coverage matches traditional Medicare in most cases
Costs and Out-of-Pocket
What You’ll Typically Pay
| Cost Component | Typical Range |
|---|---|
| Deductible | $0-$1,500+ (varies by plan) |
| Copay (specialist) | $30-$75 per visit |
| Coinsurance | 20-40% after deductible |
| Out-of-pocket max | Plan-specific |
In-Network vs. Out-of-Network
Important: Going out-of-network can significantly increase costs:
- Higher deductible applies
- Higher coinsurance (often 40-50%)
- Balance billing possible
- May not count toward in-network out-of-pocket max
Always verify your provider is in-network before treatment.
If You’re Denied
Common Denial Reasons
- Prior authorization not obtained - Most common fixable issue
- Insufficient documentation - Need more treatment history
- Criteria not met - May need to try other treatments first
- Out of network - Higher costs or no coverage
- Plan exclusion - HA specifically excluded (rare)
Appeal Process
UHC Appeal Steps:
- Request written denial explanation - Call number on denial letter
- Gather documentation - Medical records, imaging, treatment history
- Provider letter of medical necessity - Explains why HA is appropriate
- Submit formal appeal - Within 180 days of denial
- Request peer-to-peer - Your doctor speaks with UHC medical director
- External review - If internal appeals fail
Contact Information
- Member Services: Number on your insurance card
- Prior Authorization: (800) 366-7312 (varies by plan)
- Appeals Address: Listed on denial letter
Comparing UHC to Other Insurers
| Factor | UHC | Some Competitors |
|---|---|---|
| HA Policy | ”Proven and medically necessary" | "Not routinely covered” or “experimental” |
| Coverage | Generally covered with criteria | Varies widely |
| Prior Auth | Usually required | Varies |
| Trend | Maintaining coverage | Some reducing coverage |
Key Takeaways
UnitedHealthcare Coverage Summary
Good news for UHC members:
- HA injections are classified as “proven and medically necessary”
- Coverage available when criteria are met
- No indication of plans to remove coverage
What you need to do:
- Verify your specific plan covers HA - Call member services
- Use in-network providers - Significant cost savings
- Obtain prior authorization - Don’t skip this step
- Document conservative treatment - Required for approval
- Appeal if denied - Many denials are overturned with proper documentation
Find In-Network Providers
Locate providers who accept UnitedHealthcare and specialize in knee injections.
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Thank You!
We've received your request. A provider specialist will contact you within 1-2 business days to help you find the right care.
What happens next?
- 1 We'll verify your insurance coverage
- 2 Match you with quality providers in your area
- 3 Contact you to discuss your options
Questions? Browse our guides:
How to Choose a ProviderReferences
-
UnitedHealthcare Medical Policy - Sodium Hyaluronate Injections. [UHC Provider Portal]
-
UHC Clinical Policy - Viscosupplementation Coverage Guidelines.
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