Anthem Blue Cross ConnecticutCommercial Clinical Policy

SURG.00105 Bicompartmental Knee Arthroplasty Form

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Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses bicompartmental knee arthroplasty.

Position Statement

Investigational and Not Medically Necessary:

Bicompartmental knee arthroplasty is considered investigational and not medically necessary.