Harvard Pilgrim HealthCare Medical Policy

Inpatient Setting for Elective Total Joint Arthroplasty; Hip and Knee

Subject: Inpatient Setting for Elective Total Joint Arthroplasty; Hip and Knee

Background: Providers and patients have recognized the benefits associated with procedures performed in the outpatient setting with same day discharge to home. The Centers for Medicare & Medicaid Services (CMS) have recently made decisions to remove total knee arthroplasty and total hip arthroplasty from the Medicare inpatient-only (IPO) list of procedures and allow for these procedures to be performed in an outpatient setting.

Although it is appropriate for total joint arthroplasty procedures, hip and knee, to be performed in the outpatient setting, there is a select group of patients for whom elective hip or knee arthroplasty may be more appropriately performed in the inpatient setting.

Note: Total hip arthroplasty and total knee arthroplasty procedures are subject to National Imaging Associates' (NIA) prior authorization requirements. Refer to Spinal Conditions Management Programs page.

Policy and Coverage Criteria:

Policy and Coverage Criteria: The Plan will allow elective total joint arthroplasty, hip and knee, to be performed in the inpatient setting for certain groups of patients when criteria are met. The inpatient criteria for elective joint arthroplasty, hip and knee, detailed below will apply when the elective procedure is to be performed for one of the following conditions at an inpatient level of care:

• Osteoarthritis
• Post-traumatic arthritis
• Avascular necrosis (osteonecrosis), tibial plateau or femoral condyle
• Avascular necrosis (osteonecrosis), femoral head
• Nonunion or malunion, articular fracture

INPATIENT CRITERIA for ELECTIVE JOINT ARTHROPLASTY, HIP and KNEE

I. All of the following must be met:

1. A. Planned surgery is for removal and/or revision of initial joint prosthesis OR
2. B. Planned surgery is for bilateral hip or knee joint replacement, OR
3. C. Member has ONE of the following co-morbidities and this co-morbidity increases surgical risk:
   1. Moderate to severe chronic lung disease (e.g., chronic obstructive pulmonary disease, asthma, interstitial lung disease, pulmonary hypertension, respiratory failure)
   2. Heart failure defined as New York Heart Association (NYHA) Classification III and IV
   3. Unstable angina, with continued symptoms
   4. Moderate to severe cirrhosis defined as Pugh-Child score B and C
   5. Chronic kidney disease moderate-severe defined as stage G3b, End stage renal disease (ESRD)
   6. History of thromboembolic event(s), history of blood clotting or bleeding disorders
   7. Poorly controlled diabetes mellitus (DM), defined as A1C≥8 and/or short-term need for frequent blood sugar monitoring and adjustments in treatment
   8. BMI ≥ 40 kg/m²
   9. Untreated obstructive sleep apnea
4. D. Member does not have appropriate resources to support outpatient post-operative care due to one or more of the following barriers:
   1. Member lives alone and has no available caregiver
   2. History of pain management difficulty

HPHC Medical Policy

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Inpatient Setting for Elective Total Joint Arthroplasty; Hip and Knee

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HPHC policies are based on medical science, and written for the majority of people with a given condition.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g.

Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

3. Impaired functional status unrelated to joint condition
4. Impaired safety awareness (e.g. cognitive, visual, speech) which may negatively impact post-operative rehabilitation at home, including compliance with post-procedure protocol

E. Member is high anesthesia risk defined as American Society of Anesthesiologists Anesthesia Physical Classification System III or IV