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Point32Commercial Clinical Policy

Point32 Hip/Knee/Shoulder Surgeries Prior Authorization (PM) Form


Hip Arthroplasty

Notes: Refer to NIA's Clinical Guidelines for specific indications.

Indications

(899908) Is the patient's hip surgery for a revision/conversion hip arthroplasty as described by CPT codes 27132, 27134, 27137, or 27138? 

Contraindications

(899909) Is the hip surgery elective and unrelated to the clinical indications outlined by NIA's guidelines? 

Total Hip Arthroplasty/Resurfacing

Indications

(899910) Is the hip surgery a total hip arthroplasty/resurfacing as defined by CPT codes 27130 or S2118? 

Contraindications

(899911) Is the hip surgery elective and not according to NIA's clinical guidelines for hip disorders? 

Femoroacetabular Impingement Surgery

Notes: CAM/Pincher and Labral Repair procedures are included.

Indications

(899912) Is the patient undergoing a femoroacetabular impingement (FAI) surgery as per CPT codes 29914, 29915, 29916, 29863, or 29862? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

01/01/2023

Last Reviewed

02/07/2020

Original Document

  Reference



Harvard Pilgrim’s Hip/Knee/Shoulder Surgeries (HKSS) prior authorization program

Harvard Pilgrim’s Hip/Knee/Shoulder Surgeries (HKSS) prior authorization program is managed through an arrangement with National Imaging Associates (NIA).

Non-emergent Hip, Knee and Shoulder services listed below are managed through the HKSS Management and Prior Authorization program:

National Imaging Associates

NIA is NCQA-certified and URAC-accredited, and manages Harvard Pilgrim’s outpatient advanced imaging program, select spine services and sleep studies.

NIA has developed clinical guidelines that outline the key surgical treatments and clinical indications for common hip, knee and shoulder disorders. These guidelines are based on practice experiences, literature reviews, specialty criteria sets, expert opinions from leading orthopedic and sports medicine clinical leaders, and empirical data.

NIA’s Clinical Guidelines can be found on its website www.radmd.com, and are presented in a PDF file format that can be printed for future reference.