Hip Replacement Surgery Form

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Hip Replacement Surgery Medical Guideline

Service: Hip Replacement Surgery (Total Hip Arthroplasty, Hemiarthroplasty, Hip Resurfacing Arthroplasty, Revision or Replacement of Total Hip Arthroplasty) and Pain Associated with Osteoarthritis (OA)

PUM 250-0015-1812

Medical Guideline Committee Approval Q3-2025 Effective Date 03/01/2026

Related Medical Guidelines:

• Non-covered Services and Procedures Medical Guideline • DME: Pneumatic Compression Devices Medical Guideline

Coverage for Hip replacement surgery may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

Hip replacement (also called hip arthroplasty) is the surgical replacement of damaged bone and cartilage from the hip joint with a man-made implant.

 NOTE: Only devices/prosthetics approved by the U.S. FDA (United States Food and Drug Administration) may be used. It is the surgeon’s responsibility to ensure the device/prosthetic used is FDA-approved. See also, Limitations of Coverage.

I. Indications of Coverage:

A. Hip Arthroplasty is considered medically necessary for any of the following conditions:

1. Degenerative joint disease (DJD) when ALL (a. through d.) of the following are met:

   a. The individual has trialed analgesic/anti-inflammatory medication for at least 2 weeks, unless contraindicated. b. Moderate to severe arthritis shown on imaging.
   c. Documentation of at least one of the following: i. Average pain level of 6 or greater on a scale of 0 to 10

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ii. Intermittent or continuous pain that is causing a functional disability that interferes with ADLs (activities of daily living). iii. Oxford Hip score of 29 or less

d. Examination reveals at least one of the following: Pain with passive range of motion (ROM) of the hip, decreased ROM of the hip, or antalgic gait.

2. Acute femoral neck or acetabular fracture

3. Intertrochanteric hip fracture or per-trochanteric hip fracture with any one or more of the following:

   a. Avascular necrosis of femoral head on same hip b. The fracture is unstable or significantly displaced. c. The fracture is comminuted (broken, crushed, or splintered into more than two pieces). d. Inflammatory arthritis present e. Bone quality is poor f. Osteoarthritis of the same hip g. Internal fixation complication h. Neglected fracture (There has been a delay from time of injury to seeking medical treatment).

4. Failed repair / failed healing of previous hip fracture that is causing pain or functional disability that interferes with ADLs.

5. Malignancy affecting the pelvic bones, the proximal femur or associated soft tissues.

6. Chronic dislocation of hip

7. Hemophilic or inflammatory arthropathy with documentation of all of the following: Advanced arthritic changes, decreased range of motion, pain or functional disability that interferes with ADLs, and other interventions (e.g., synovectomy, arthrodesis, or osteotomy) are not appropriate or have failed.

8. Congenital deformity or hip dysplasia that is causing pain or functional disability that interferes with ADLs.

9. Symptomatic osteonecrosis of the femoral head with collapse or imaging demonstrating arthritis (Ficat stage II or higher).

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Hip replacement surgery (hip arthroplasty) using an FDA-approved device with customized prosthesis and/or patient specific instruments is considered medically necessary for use with: a. Complex periarticular hip or pelvis fractures; OR b. Revision arthroplasty required due to periprosthetic fracture. For all other indications, use of customized/personalized prostheses and/or patient- specific cutting instruments is considered not medically necessary.

Imaging studies (CT or MRI) designed to assist with manufacture of custom prostheses or for patient specific instruments will be considered medically necessary only if criteria from a. or b. above are met.

B. Revision of Previous Hip Arthroplasty Procedure or Previous Resurfacing Procedure is considered medically necessary for any of the following conditions that are causing the individual pain or functional disability that interferes with ability to perform ADLs:

1. Mechanical failure, fracture, or loosening of prosthetic (demonstrated on imaging).

2. Nonunion of previous hip replacement (demonstrated on imaging).

3. Recurrent hip dislocations (demonstrated on imaging) that are non- responsive to conservative management.

4. Hip dislocation that is irreducible

5. Periprosthetic infection (culture or gram stain confirmed)

6. Periprosthetic fracture (demonstrated on imaging)

7. Leg length discrepancy that is significant and affects gait or functional ability.

8. Metallosis or hypersensitivity reaction caused by previous hip implant.

   NOTE: Please see MCG for surgical setting, length of stay, postoperative rehabilitation or SNF reviews.

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Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

1. Review contract and endorsements for exclusions and prior authorization or benefit limits or requirements

2. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes

3. If used for a condition/diagnosis that is listed in the Indications of Coverage, but the criteria are not met, it will be considered not medically necessary

4. All of the following will be considered not medically necessary:

   a. Patient-specific instruments, except as noted under Indications of Coverage above b. Custom implants/prostheses (such as, but not limited to the Conformis Hip System) and imaging (CT or MRI) designed to assist with manufacture of custom prostheses or for patient-specific instruments, or for planning intraoperative navigation; except as noted under Indications of Coverage above.

5. All of the following will be considered experimental, investigational, and unproven to affect health outcomes:

   a. Metal on metal hip resurfacing for individuals greater than 65 years old b. Intraoperative surgical navigation (including, but not limited to intellijoint HIP®, OrthoGrid Hip AI) or robotic assistance for hip arthroplasty (Mako SmartRobotics) are considered integral to the surgical procedure. c. Radlink Galileo Positioning System (GPS)
   d. Home use of CPM (continuous passive motion) devices and related
   equipment/supplies e. Use of a device/prosthetic that has not been approved by the U.S. FDA for the specific use planned f. iovera® System g. Coolief® Cooled RF (radiofrequency) h. Viscosupplementation, hyaluronic acid injections i. Stem cell therapy or stem cell injections j. Platelet-rich plasma injections

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k. Peripheral nerve block of the articular branches of the femoral or obturator nerve, unless provided intraoperatively l. Radiofrequency ablation (RFA) of the articular branches of the femoral or obturator nerve
m. Cryotherapy, cold therapy devices n. Bone marrow aspirate concentrate (BMAC) injection/treatment o. Microfragmented adipose tissue (MFAT) injection/treatment (such as, but not limited to Lipogems®) p. Platelet Lysate (PL) q. 3D-printed orthopedic implants

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. History and physical notes (including physical/functional impairments and pain caused by hip). Imaging studies. Documentation of conservative treatment trials (medication, physical therapy, etc.). Therapy evaluation and daily progress notes (for review of extensions for inpatient rehabilitation facility or skilled nursing facility). Nursing assessment and progress notes (for review of extensions for skilled nursing facility due to nursing need, as indicated in MCG noted above.)
• Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com.
Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Hip Replacement surgery is considered medically necessary when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

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                                                                      Approved by the Medical Director

Guideline Review History:

Implemented 04/01/19, 01/01/20, 12/01/20, 04/01/21, 12/01/21, 03/01/23, 01/01/24, 11/01/24, 03/01/26 Medical Guideline Committee Approval 12/14/18, 09/27/19, 10/30/20, 11/19/20, 11/18/21, 12/15/22, 12/14/23, 10/31/24, Q3 2025 Reviewed

09/27/19, 11/19/20, 11/18/21, 12/15/22, 12/14/23, 10/31/24, Q3 2025 Developed 12/14/18

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 0396T INTRA-OPERATIVE USE OF KINETIC BALANCE SENSOR FOR IMPLANT STABILITY DURING KNEE REPLACMEENT ARTHROPLASTY 20985 COMPUTER ASSISTED SURGICAL NAVIGATION PROCEDURE FOR MUSCULOSKELETAL PROCEDURES 27125 HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, BIPOLAR ARTHROPLASTY 27130 ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT 27132 CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT 27134 REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT 27137 REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT 27138 REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT

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S2118 METAL ON METAL TOTAL HIP RESURFACING, INCLUDING ACETABULAR AND FEMORAL COMPONENTS S2900 SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM 0SPR0JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM RIGHT HIP JOINT, FEMORAL SURFACE, OPEN APPROACH
0SR901A REPLACEMENT OF RIGHT HIP JOINT WITH METAL SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SR901Z REPLACEMENT OF RIGHT HIP JOINT WITH METAL SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SR902A REPLACEMENT OF RIGHT HIP JOINT WITH METAL ON POLYETHYLENE SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SR902Z REPLACEMENT OF RIGHT HIP JOINT WITH METAL ON POLYETHYLENE SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SR903A REPLACEMENT OF RIGHT HIP JOINT WITH CERAMIC SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SR903Z REPLACEMENT OF RIGHT HIP JOINT WITH CERAMIC SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SR904A REPLACEMENT OF RIGHT HIP JOINT WITH CERAMIC ON POLYETHYLENE SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SR904Z REPLACEMENT OF RIGHT HIP JOINT WITH CERAMIC ON POLYETHYLENE SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SR906A REPLACEMENT OF RIGHT HIP JOINT WITH OXIDIZED ZIRCONIUM ON POLYETHYLENE SYNTHETIC SUBSTITUTE, UNCEMENTED,OPEN APPROACH
0SR90JA REPLACEMENT OF RIGHT HIP JOINT WITH SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SR90JZ RREPLACEMENT OF RIGHT HIP JOINT WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SRB02A REPLACEMENT OF LEFT HIP JOINT WITH METAL ON POLYETHYLENE SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB03A REPLACEMENT OF LEFT HIP JOINT WITH CERAMIC SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB03Z REPLACEMENT OF LEFT HIP JOINT WITH CERAMIC SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SRB049 REPLACEMENT OF LEFT HIP JOINT WITH CERAMIC ON POLYETHYLENE SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH

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0SRB04A REPLACEMENT OF LEFT HIP JOINT WITH CERAMIC ON POLYETHYLENE SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB04Z REPLACEMENT OF LEFT HIP JOINT WITH CERAMIC ON POLYETHYLENE SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SRB06Z REPLACEMENT OF LEFT HIP JOINT WITH OXIDIZED ZIRCONIUM ON POLYETHYLENE SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SRB0JA REPLACEMENT OF LEFT HIP JOINT WITH SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB0JZ REPLACEMENT OF LEFT HIP JOINT WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH
0SRR03A REPLACEMENT OF RIGHT HIP JOINT, FEMORAL SURFACE WITH CERAMIC SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SU90BZ SUPPLEMENT RIGHT HIP JOINT WITH RESURFACING DEVICE, OPEN APPROACH
0SWB04Z REVISION OF INTERNAL FIXATION DEVICE IN LEFT HIP JOINT, OPEN APPROACH
0SRS03A REPLACEMENT OF LEFT HIP JOINT, FEMORAL SURFACE WITH CERAMIC SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRR03A REPLACEMENT OF RIGHT HIP JOINT, FEMORAL SURFACE WITH CERAMIC SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB029 REPLACEMENT OF LEFT HIP JOINT WITH METAL ON POLYETHYLENE SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH
0SR9029 REPLACEMENT OF RIGHT HIP JOINT WITH METAL ON POLYETHEYLENE SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH
0SRS01A REPLACEMENT OF LEFT HIP JOINT, FEMORAL SURFACE WITH METAL SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRR01A REPLACEMENT OF RIGHT HIP JOINT, FEMORAL SURFACE WITH METAL SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB06A REPLACEMENT OF LEFT HIP JOINT WITH OXIDIZED ZIRCONIUM ON POLYETHYLENE SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH
0SRB0J9 REPLACEMENT OF LEFT HIP JOINT WITH SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH
0SR90J9 REPLACEMENT OF RIGHT HIP JOINT WITH SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH

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