Total Knee and Hip Replacement — Preauthorization Requirement for Specified Member Groups
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Policy governing preauthorization and coverage requirements for total knee and total hip replacement for specified BCBSNE member groups (EHA, MUD, BCBSNE employees/dependents, and Individual ACA). Applies to those identified product prefixes and the providers submitting claims for those members.
Added prefix YAW effective 1/1/2025 and added ACA prefix YCV effective 1/1/2025.
Coverage criteria for total hip and total knee replacement
Covered when ALL of the following are met
Coverage is contingent on meeting InterQual clinical criteria and obtaining preauthorization for specified member groups.
If preauthorization is not obtained, the claim will be denied as provider liability; if preauthorization is obtained but InterQual criteria are not met and the member elects to proceed with written authorization, the claim will be denied as member liability and post-discharge services related to the procedure will also be member liability.
Coverage for total knee and total hip replacement is contingent on both preauthorization and meeting InterQual clinical criteria. This preauthorization requirement applies to members in the specified product prefixes: EHA (EHN), MUD (MET), BCBSNE employees/dependents (NEQ), and Individual ACA (YST, YNQ, YCV, YAW). If these conditions are not met, the services are not covered under this policy.
If BCBSNE determines after a submitted pre-service authorization that the care does not meet the policy criteria, benefits are not available and the services are considered not medically necessary under this policy. Should the member elect to proceed despite a denial and provide written authorization, the claim will be processed as member liability, and any post-discharge services necessitated by the procedure will also be the member's financial responsibility.
Procedure and billing codes
| 0SRC0L9 | Replace of R Knee Jt with Unicondyl, Cement, Open Approach |
| 0SRC0LA | Replace of R Knee Jt with Unicondyl, Uncement, Open Approach |
| 0SRC0LZ | Replacement of R Knee Jt with Unicondyl, Open Approach |
| 0SRD0L9 | Replace of L Knee Jt with Unicondyl, Cement, Open Approach |
| 0SRD0LA | Replace of L Knee Jt with Unicondyl, Uncement, Open Approach |
| 0SRD0LZ | Replacement of Left Knee Jt with Unicondyl, Open Approach |
| 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 |
| 27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) |
Authorization, documentation, and denial guidance for providers
Obtain preauthorization for listed member groups
Preauthorization is required for total knee and total hip replacement for members and dependents in the listed product prefixes (EHA EHN, MUD MET, BCBSNE employees/dependents NEQ, and Individual ACA YST, YNQ, YCV, YAW). Failure to obtain preauthorization will result in claim denial as provider liability; claims may be held for review to determine post-discharge coverage eligibility.
- Applies only to the specified groups: EHA (EHN), MUD (MET), BCBSNE employees/dependents (NEQ), and Individual ACA (YST, YNQ, YCV, YAW).
- Preauthorization is required for coverage of the listed CPT and ICD-10-PCS procedure codes.
Provide InterQual documentation with authorization request
Authorization decisions use InterQual clinical criteria; providers must submit necessary clinical documentation during the preauthorization request to support InterQual review.
- Include clinical information and documentation required by InterQual to demonstrate medical necessity.
- Reference the InterQual criteria linked in the policy when preparing the request.
Use InterQual criteria for review
BCBSNE bases authorization decisions on InterQual clinical criteria and expects providers to supply documentation necessary for InterQual review as part of the preauthorization process.
- Ensure submitted records address the specific InterQual criteria elements cited for total hip and knee replacement.
Risk of denial when no preauthorization obtained
If a pre-service authorization is not completed for these services, claims will be denied as provider liability without opportunity to balance bill the BCBSNE member; the claim may be held for review to determine if post-discharge services are eligible for coverage.
- Do not perform services for affected members without obtaining preauthorization if you expect BCBSNE payment for the procedure.
- Denial in this circumstance is the provider's financial responsibility.
Denial and member liability if criteria not met
If a preauthorization request is submitted but BCBSNE determines the InterQual criteria are not met, benefits are not available; if the member elects to receive services despite denial and provides written authorization, the claim will be denied as member liability and related post-discharge services will also be member liability.
- Obtain written member acknowledgment if the member chooses to proceed after a denial — the claim will be billed to the member, not BCBSNE.
- Post-discharge services necessitated by the procedure will be the member's financial responsibility when criteria are not met.
Background and rationale
This policy uses InterQual clinical criteria as the standard for assessing medical necessity for total hip and total knee arthroplasty. Authorization decisions are based on those InterQual criteria and providers must supply the documentation necessary for InterQual review as part of the preauthorization process.
Definitions and referenced criteria
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