Total Joint Arthroplasty – Hip and Knee Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 03|01|2025 POLICY LAST REVIEWED: 08|20|2025

OVERVIEW Joint replacement surgery, also known as arthroplasty, has proved to be an important medical advancement. Arthroplasty surgery is most commonly performed for diseases which affect the function of the hip joint and knee joint, but is also performed on ankles, shoulders, and phalanges. In addition, the arthroplasty may be total (involving the entire joint) or partial (involving less than the entire joint).

Note: This policy is applicable for Commercial Products only. For Medicare Advantage Plans, see the applicable policy in the Related Policies section.

MEDICAL CRITERIA Commercial Products Total Knee Arthroplasty (TKA) A total knee arthroplasty is considered medically necessary for individuals with one or more of the following (1, 2, 3, 4 or 5):

1. Osteoarthritis or posttraumatic arthritis as demonstrated by meeting all of the following (a,b,c,d,e,f,g,h):
   a. Individual is 18 years old or older
   b. Must have at least 1 of the following: • Pain interferes with activities of daily living (ADLs) • Pain with range of motion (ROM) c. Must have at least 2 of the following: • Limited range of motion (ROM) • Crepitus • Joint effusion or swelling d. Must have at least ONE of the following (Needs to meet 1 or 2):
2. Imaging shows bone-on-bone contact OR

3. There is no bone-on-bone contact, but has at least 2 of the following 5 findings: o Subchondral cysts o Subchondral sclerosis o Periarticular osteophytes o Joint subluxation o Joint space narrowing AND must meet ALL the following: o The individual must have tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): ▪ NSAIDs or acetaminophen >3 weeks or intra-articular corticosteroid injection > 1 injection ▪ PT or home exercise >12 weeks ▪ Activity modification >12 weeks e. There is no active infection f. Obesity: BMI <40 g. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery h. Diabetes control: HgbA1C < 8.1% OR not diabetic

4. Avascular necrosis (osteonecrosis) as demonstrated by meeting all of the following (a,b,c,d,e,f,g,h,i):
   Medical Coverage Policy | Total Joint Arthroplasty – Hip and Knee

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

a. Individual is 18 years old or older
b. Must have at least 1 of the following: • Pain interferes with activities of daily living (ADLs) • Pain with range of motion (ROM) c. Must have at least 2 of the following: • Limited range of motion (ROM) • Crepitus • Joint effusion or swelling

  d. Imaging shows avascular necrosis

e. Must have ONE of the following: • There is collapse of tibial plateau or femoral condyle OR • There is no collapse of tibial plateau or femoral condyle, however, the individual has tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): o NSAIDs or acetaminophen >3 weeks o PT or home exercise >12 weeks o Activity modification >12 weeks f. There is no active infection g. Obesity: BMI <40 h. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery i. Diabetes control: HgbA1C < 8.1% OR not diabetic

3. Bone tumor involving the knee seen on imaging as demonstrated by meeting all of the following (a,b,c,d,e,):
   a. Individual is 18 years old or older
   b. There is no active infection c. Obesity: BMI <40 d. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery e. Diabetes control: HgbA1C < 8.1% OR not diabetic
   4. Nonunion or malunion, articular fracture as demonstrated by meeting all of the following (a,b,c,d,e,f): a. Individual is 18 years old or older
      b. Symptomatic nonunion or malunion of fracture c. There is no active infection d. Obesity: BMI <40 e. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery f. Diabetes control: HgbA1C < 8.1% OR not diabetic
      5. Rheumatoid arthritis as demonstrated by meeting all of the following (a,b,c,d,e,f,g,h,i): a. Individual is 18 years old or older
         b. Must have at least 1 of the following: • Pain interferes with activities of daily living (ADLs) • Pain with range of motion (ROM) c. Must have at least 2 of the following: • Limited range of motion (ROM) • Crepitus • Joint effusion or swelling d. Imaging shows at least 2 of the following: • Subchondral cysts • Marginal erosions • Periarticular osteopenia • Joint subluxation • Joint space narrowing

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

e. The individual has tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): o Disease modifying antirheumatic drugs >12 weeks o PT or home exercise >12 weeks o Activity modification >12 weeks f. There is no active infection g. Obesity: BMI <40 h. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery i. Diabetes control: HgbA1C < 8.1% OR not diabetic

Replacement/Revision Knee Arthroplasty A removal and replacement of a total knee arthroplasty is considered medically necessary when ALL of the following has been met:
• Individual is 18 years old or older AND
• Must have at least ONE of the following (1, 2, 3,4, 5, 6):

1. Recurrent dislocation by imaging
2. Worn or dislocated plastic insert by imaging
3. Malposition of tibial or femoral component by imaging

4. Symptomatic loosening of prosthesis or cement by imaging

   AND ALL of the following for the above indications (1, 2, 3, 4) ▪ Obesity: BMI <40 AND ▪ Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery AND ▪ Diabetes control: HgbA1C < 8.1% OR not diabetic
   ▪ There is no active infection

5. Fractured prosthesis or cement by imaging with no active infection

6. Joint infection with ONE of the following: o Joint infection with sinus tract communicating with prosthetic joint by imaging
   OR o Joint infection without sinus tract communicating with prosthetic joint by imaging or without prosthetic joint infection by positive synovial fluid culture or tissue culture and ALL of the following (a, b, c, d) AND

   a. Must have one of the following:

7. Joint Pain

8. Erythema or drainage or swelling at joint by physical

   examination

   b. Must have 2 of the following:

9. Temperature > 100.4 F (38.0 C)

10. Synovial WBC or neutrophil percentage > normal

11. ESR > 30 mm/hr

12. C-reactive protein > normal

    c. Joint infection onset within 4 weeks of total joint replacement or new

    joint symptoms and findings ≤ 3 weeks

    d. Prosthesis or cement on imaging shows: ▪ Loosening OR
    ▪ No loosening and the individual has been treated with IV anti- infectives >4 weeks and has had a joint lavage with continued symptoms or findings after treatment OR o Prosthetic joint infection by positive synovial fluid culture or tissue culture with ALL of the following (a,b,c):

    a. Infection as demonstrated by at least ONE of the following:

    o Two cultures positive for the same organism OR o Culture positive for staphylococcus aureus OR o Culture positive for gram–negative organism OR

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

o Culture positive for enterococci AND;

b. Joint infection onset within 4 weeks of total joint replacement or new

joint symptoms and findings ≤ 3 weeks

d. Prosthesis or cement on imaging shows:

1. Loosening OR

2. No loosening and the individual has been treated with IV anti-

   infectives >4 weeks and has had a joint lavage with continued

   symptoms or findings after treatment Total Hip Arthroplasty (THA) A total hip arthroplasty is considered medically necessary for individuals with one or more of the following (1, 2, 3, 4, 5 or 6):

3. Osteoarthritis or posttraumatic arthritis as demonstrated by meeting all of the following (a,b,c,d,e,f,g,h):
   a. Individual is 18 years old or older
   b. Must have at least 2 of the following: • Pain increased with initiation of activity • Pain increased with weight bearing • Pain interferes with activities of daily living (ADLs) • Pain with range of motion (ROM) c. Must have BOTH of the following: • Limited range of motion (ROM) • Antalgic gait d. Must have at least ONE of the following (Needs to meet 1 or 2):
4. Imaging shows bone-on-bone contact OR

5. There is no bone-on-bone contact, but has at least 2 of the following 5 findings: o 1. Subchondral cysts o 2. Subchondral sclerosis o 3. Periarticular osteophytes o 4. Joint subluxation o 5. Joint space narrowing AND must meet ALL of the following: o And The individual must have tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): ▪ NSAIDs or acetaminophen >3 weeks ▪ PT or home exercise >12 weeks ▪ Activity modification >12 weeks e. There is no active infection f. Obesity: BMI <40 g. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery h. Diabetes control: HgbA1C < 8.1% OR not diabetic

6. Femoral head avascular necrosis (osteonecrosis) as demonstrated by meeting all of the following (a,b,c,d,e,f,g,h,i):
   a. Individual is 18 years old or older
   b. Must have at least 2 of the following: • Pain increased with initiation of activity • Pain increased with weight bearing • Pain interferes with activities of daily living (ADLs) • Pain with range of motion (ROM) c. Must have at least ONE of the following: • Limited range of motion (ROM) • Antalgic gait d. Imaging shows avascular necrosis

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

  e. Must have ONE of the following:

• There is stage III or IV collapse of femoral head OR • There is no stage III or IV collapse of femoral head, however, the individual has tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): o NSAIDs or acetaminophen >3 weeks o PT or home exercise >12 weeks o Activity modification >12 weeks f. There is no active infection g. Obesity: BMI <40 h. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery i. Diabetes control: HgbA1C < 8.1% OR not diabetic

  3. Nonunion or malunion, articular fracture as demonstrated by meeting all of the following

(a,b,c,d,e,): a. Individual is 18 years old or older
b. Symptomatic nonunion or malunion of fracture c. There is no active infection c. Obesity: BMI <40 d. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery e. Diabetes control: HgbA1C < 8.1% OR not diabetic

 4. Rheumatoid arthritis as demonstrated by meeting all of the following (a,b,c,d,e,f,g,h,i):

a. Individual is 18 years old or older
b. Must have at least 2 of the following: • Pain increased with initiation of activity • Pain increased with weight bearing • Pain interferes with activities of daily living (ADLs) • Pain with range of motion (ROM) • Pain at night c. Must have BOTH of the following: • Limited range of motion (ROM) • Antalgic gait d. Imaging shows at least 2 of the following: • Subchondral cysts • Marginal erosions • Periarticular osteopenia • Joint subluxation • Joint space narrowing e. The individual has tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): o Disease modifying antirheumatic drugs >12 weeks o PT or home exercise >12 weeks o Activity modification >12 weeks f. There is no active infection g. Obesity: BMI <40 h. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery i. Diabetes control: HgbA1C < 8.1% OR not diabetic

5. Bone tumor involving the hip seen on imaging as demonstrated by meeting all of the following (a,b,c,d,e,):
   a. Individual is 18 years old or older
   b. There is no active infection c. Obesity: BMI <40 d. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 6 (401) 274-4848 WWW.BCBSRI.COM

e. Diabetes control: HgbA1C < 8.1% OR not diabetic

  6. Acute hip fracture by imaging as demonstrated by meeting all of the following (a,b,c,d,e,f):

a. Individual is 18 years old or older
b. Must have ONE of the following: • Comminuted or impacted acetabular fracture • Displaced femoral head or neck fracture • Intertrochanteric or subtrochanteric fracture and repair has failed or not feasible • Arthritis of acetabulum or femoral head by imaging AND at least 2 of the following: o Subchondral cysts o Subchondral sclerosis o Marginal erosions o Periarticular osteophytes o Periarticular osteopenia o Joint subluxation o Joint space narrowing c. There is no active infection d. Obesity: BMI <40 e. Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery f. Diabetes control: HgbA1C < 8.1% OR not diabetic

Replacement/Revision Hip Arthroplasty A removal and replacement of a total hip arthroplasty is considered medically necessary when ALL of the following has been met:
• Individual is 18 years old or older AND
• Must have at least ONE of the following (1, 2, 3, 4, 5, 6):

1. Recurrent dislocation by imaging
2. Malposition of acetabular or femoral component by imaging
3. Symptomatic loosening of prosthesis or cement by imaging

4. Thigh pain with uncemented component with ALL of the following (a,b)

   a. Thigh pain > 6 months

   b. The individual has tried ALL of the following treatments within the last year (with continued symptoms or findings after treatments): o NSAIDs or acetaminophen >3 weeks o PT or home exercise >12 weeks o External joint support > 12 weeks o Activity modification >12 weeks AND ALL of the following for the indications (1, 2, 3, 4) ▪ Obesity: BMI <40 AND ▪ Tobacco use: 4 weeks off of tobacco use prior to scheduled surgery AND ▪ Diabetes control: HgbA1C < 8.1% OR not diabetic AND ▪ There is no active infection

   5. Fractured prosthesis or cement by imaging with no active infection

5. Joint infection with ONE of the following: o Joint infection with sinus tract communicating with prosthetic joint by imaging
   OR o Joint infection without sinus tract communicating with prosthetic joint by imaging or without prosthetic joint infection by positive synovial fluid culture or tissue culture and ALL of the following (a, b, c, d) AND

   a. Must have one of the following:

6. Joint Pain

7. Erythema or drainage or swelling at joint by physical

   examination

   b. Must have 2 of the following:

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 7 (401) 274-4848 WWW.BCBSRI.COM

1. Temperature > 100.4 F (38.0 C)

2. Synovial WBC or neutrophil percentage > normal

3. ESR > 30 mm/hr

4. C-reactive protein > normal

   c. Joint infection onset within 4 weeks of total joint replacement or new

   joint symptoms and findings ≤ 3 weeks

   d. Prosthesis or cement on imaging shows: ▪ Loosening OR
   ▪ No loosening and the individual has been treated with IV anti- infectives >4 weeks and has had a joint lavage with continued symptoms or findings after treatment OR o Prosthetic joint infection by positive synovial fluid culture or tissue culture with ALL of the following (a,b,c):

   a. Infection as demonstrated by at least ONE of the following:

   o Two cultures positive for the same organism OR o Culture positive for staphylococcus aureus OR o Culture positive for gram–negative organism OR o Culture positive for enterococci AND;

   b. Joint infection onset within 4 weeks of total joint replacement or new

   joint symptoms and findings ≤ 3 weeks

   c. Prosthesis or cement on imaging shows:

5. Loosening OR

6. No loosening and the individual has been treated with IV anti-

   infectives >4 weeks and has had a joint lavage with continued

   symptoms or findings after treatment PRIOR AUTHORIZATION
   Commercial Products Prior authorization is recommended for Commercial Products and is obtained via the online tool for participating providers. See Related Policies section.

   POLICY STATEMENT Commercial Products Total hip and knee arthroplasties are considered medically necessary when the above medical criteria has been met.

   COVERAGE Benefits may vary between groups and contracts. Please refer to the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable surgery benefit/coverage.

   BACKGROUND Total Knee Arthroplasty (TKA) The knee joint includes the lower end of the femur, the upper end of the tibia and the patella. The knee joint has three compartments, the medial, the lateral and the patellofemoral. The surfaces of these compartments are normally covered with articular cartilage and are bathed in synovial fluid. The most common reason for knee arthroplasty is arthritis of the knee joint. Arthritis may cause pain, stiffness, or other symptoms which limit normal activities such as walking, squatting, and climbing stairs. Additional indications for knee arthroplasty include osteonecrosis, malignancy, and other degenerative conditions. The goal of knee arthroplasty is to relieve pain and improve or increase patient function.

   Total Hip Arthroplasty (THA)
   The hip joint is made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and are bathed in synovial fluid produced by a synovial membrane. Hip arthroplasty is most often performed due to symptoms arising from arthritis, osteonecrosis, malignancy, and degenerative conditions. The goal of hip arthroplasty is to relieve pain and improve or

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 8 (401) 274-4848 WWW.BCBSRI.COM

increase patient function.

Revision Arthroplasty
Revision arthroplasty is performed on an individual who has had a prior hip or knee arthroplasty. Revision arthroplasty may be needed when pain or other symptoms occur as a result of failure of the prior surgery. Failure may occur as a result of infection of the joint, bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components, wear of the prosthetic components, and for other reasons.

CODING Commercial Products The following code(s) are medically necessary when the medical criteria has been met:
Hip 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

Knee 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella

resurfacing (total knee arthroplasty) 27486 Revision of total knee arthroplasty, with or without allograft; 1 component 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

RELATED POLICIES Prior Authorization via Web-Based Tool for Procedures Medicare Advantage Plans National and Local Coverage Determinations

PUBLISHED Provider Update, October 2025 Provider Update, January 2025 Provider Update, June 2023 Provider Update, October 2022

REFERENCES

1. Centers for Medicare and Medicaid Services (CMS). National Government Services, Inc Local Coverage Determination (LCD): Total Joint Arthroplasty (L36039); https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?lcdId=36039. Accessed July 22, 2025.
2. Centers for Medicare and Medicaid Services (CMS). Palmetto GBA Local Coverage Determination (LCD): Total Joint Arthroplasty (L33456); https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?lcdId=33456&ver=71. Accessed July 22, 2025
3. Centers for Medicare and Medicaid Services (CMS). Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD): Total Joint Arthroplasty (L34163); https://www.cms.gov/medicare-coverage- database/view/lcd.aspx?lcdId=34163&ver=29. Accessed July 22, 2025
4. Centers for Medicare and Medicaid Services (CMS). First Coast Service Options, Inc Local Coverage Determination (LCD): Major Joint Replacement (Hip and Knee) (L33618); https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33618&ver=23. Accessed July 22, 2025
5. Ackerman IN, Bennell KL, Osbourne RH, et al. Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study. BMC Musculoskeletal Disorders. 2011;12:108
6. Agency for Healthcare Research and Quality (AHRQ). TotalJoint
7. Dennis DA, Berry DJ, Engh G. AAOS Symposium: Revision total knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2008:16(8):442-454.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 9 (401) 274-4848 WWW.BCBSRI.COM

8. Emedicine. Total Knee Arthroplasty Accessed 9/9/2014.
9. Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. Journal of the American Academy of Orthopaedic Surgeons. 2010;18(7):406-416.
10. InterQual® 2025 Procedures Adult Criteria, Total Joint Replacement, Knee and Hip & Removal and Replacement, Total Joint Replacement Knee and Hip. McKesson Corporation.
11. Milliman Care Guidelines® 2011. Inpatient and Surgical Care 15th Edition. Knee Arthroplasty and Hip Arthroplasty. Milliman Care Guidelines LLC.
12. O’Connor M. Implant Survival, knee function and pain relief after TKA: Are there differences between men and women? Clinical Orthopaedics & Related Research. 2011;469(7):1846-1851.
13. Orthopedic Connection (2013) Total Knee Replacement
14. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty). J Amer Acad Orthop Surg. 2009;17(9):591-600.

15. U.S. National Library of Medicine, National Institute of Health. Hip joint replacement.

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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