CurrentevicorePolicy CMM-313

Hip Replacement/ Arthroplasty

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Clinical coverage criteria for partial hip resurfacing, total hip resurfacing, partial and total hip replacement, and revision hip replacement — specifying when procedures are medically necessary or not. Applies to providers seeking authorization from eviCore for hip arthroplasty services.

Policy Summary

Payerevicore

PolicyHip Replacement/ Arthroplasty

Policy CodePolicy CMM-313

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating all applicable medical necessity criteria are met, including imaging, symptom duration, and failed conservative management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

v1.0.2026document version

6codes listed

≥3 moconservative management

≤50%AVN allowed for resurfacing

>50%

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CurrentevicorePolicy CMM-313

Hip Replacement/ Arthroplasty

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Policy Summary

Payerevicore

PolicyHip Replacement/ Arthroplasty

Policy CodePolicy CMM-313

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating all applicable medical necessity criteria are met, including imaging, symptom duration, and failed conservative management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

v1.0.2026document version

6codes listed

≥3 moconservative management

≤50%AVN allowed for resurfacing

>50%

AVN contraindication

Coverage Criteria for Hip Arthroplasty

Total Hip Resurfacing Arthroplasty Indications

Total hip resurfacing arthroplasty is considered medically necessary when ALL of the following criteria have been met:

Age is ≤64 years<=64

Surgeon should optimize modifiable comorbidities preoperatively

Imaging: Either: (1) osteoarthritis or inflammatory arthritis affecting BOTH the femoral head and acetabulum with joint space narrowing on weight-bearing radiographs; OR (2) avascular necrosis of the femoral head with possible acetabular surface involvement and less than 50% femoral head involvement

Symptoms: Function-limiting pain at short distances (e.g., walking <1/4 mile or ~2 city blocks) for at least 3 months OR documented reason why 3 months of non-surgical management is inappropriate; AND loss of hip function interfering with ADLs and/or employment>=3 months

Conservative management: Failure of provider-directed non-surgical management for at least 3 months' duration unless the medical record documents why non-surgical management is inappropriate>=3 months

Partial Hip Replacement Indications

Partial hip replacement is considered medically necessary for ANY of the following conditions when ALL associated criteria are met:

Femoral head/neck fracture: Imaging shows a fracture of the femoral head or femoral neck; AND conservative management or surgical fixation is not considered a reasonable option

Avascular necrosis (AVN) with collapse: Imaging shows AVN with collapse of the femoral head; AND symptoms include function-limiting pain at short distances for at least 3 months (or documented exception) AND loss of hip function interfering with ADLs/employment; AND failure of provider-directed non-surgical management for at least 3 months (exceptions allowed when documented)>=3 months

Total Hip Replacement Indications

Total hip replacement is considered medically necessary for ANY of the following conditions when ALL associated criteria have been met:

Femoral head/neck fracture: Imaging shows a fracture of the femoral head or femoral neck; AND conservative management or surgical fixation is not considered a reasonable option

Osteoarthritis, AVN, or inflammatory arthritis: Imaging shows ONE of: Tönnis Grade 2-3 osteoarthritis; avascular necrosis with collapse of the femoral head; OR inflammatory arthritis affecting BOTH the femoral head and acetabulum with joint space narrowing. Symptoms must include function-limiting pain at short distances for at least 3 months (or documented exception) AND loss of hip function interfering with ADLs/employment; AND failure of provider-directed non-surgical management for at least 3 months (exceptions allowed when documented)>=3 months

Revision of Hip Replacement Indications

Revision of hip replacement (partial or total) is considered medically necessary when ANY of the following post-operative conditions are present:

Revision indications

Dislocation/Subluxation: Recurrent prosthetic dislocation or subluxation unresponsive to provider-directed non-surgical management
Aseptic loosening
Periprosthetic joint infection
Periprosthetic fracture
Implant instability (e.g., disassembly, modular neck failure)

IPE — Medically Necessary Indications

Isolated Head and Polyethylene Liner Exchange (IPE) is considered medically necessary when ALL of the associated criteria have been met for the listed post-operative conditions:

IPE Indications

Eccentric polyethylene wear: Individual is symptomatic; AND implants are well-fixed and in acceptable position
Acute post-operative joint infection: Periprosthetic or hematogenous acute post-operative joint infection with well-fixed implants
Dislocation/Instability conversion: Procedure includes BOTH conversion to a liner with higher offset/larger head/dual-mobility/constrained liner AND conversion of a failed metal-on-metal or ceramic-on-ceramic bearing surface to metal-on-polyethylene or ceramic-on-polyethylene

Documentation:

Salvage Procedures — Medically Necessary Indications

Salvage procedures are considered medically necessary when performed as a surgical alternative in individuals for whom primary or revision hip replacement is not a reasonable option due to ANY of the following conditions:

Salvage Indications

Chronic infection/osteomyelitis: Chronic infection, osteomyelitis, or persistent periprosthetic joint infection
Non-ambulatory or pre-existing ambulatory dysfunction: Individual is non-ambulatory or has pre-existing ambulatory dysfunction
Comorbidities precluding successful replacement: Presence of comorbidities or diseases that would preclude a successful hip replacement
Inadequate bone stock (e.g., severe osteoporosis or after tumor resection) so insufficient bone remains to support joint replacement

Explicit Non-Indications

Revision of hip replacement, IPE, and salvage procedures have explicit non-indications statements:

Revision Non-Indication: Revision of hip replacement is not medically necessary for ANY other indication or condition beyond those listed

IPE Non-Indication: Isolated head and polyethylene liner exchange (IPE) is not medically necessary for ANY other indication or condition beyond those listed

Salvage Non-Indication: Salvage procedures are not medically necessary for ANY other indication or condition beyond those listed

Unless otherwise specified in the policy sections listing medically necessary indications, these hip arthroplasty procedures are not medically necessary for any other indication or condition. Examples of situations that render a requested procedure not medically necessary include, but are not limited to: active local or systemic infection; skeletal immaturity; vascular insufficiency or significant muscular atrophy or neuromuscular disease compromising implant stability or recovery; Charcot joint; and other specific contraindications enumerated in the policy (for example, avascular necrosis with >50% femoral head involvement for resurfacing).

Each of the post-operative procedure categories addressed in this policy — including revision hip replacement, isolated head and polyethylene liner exchange (IPE), and salvage procedures — is explicitly stated to be not medically necessary for any other indication or condition beyond the specific indications listed for that category.

The reference and bibliography pages included in this policy provide supporting literature (systematic reviews, registry reports, guideline documents, and clinical studies) relevant to hip arthroplasty outcomes and risk factors. These bibliographic sections do not themselves state additional exclusions or non-coverage rules; they are included to support the clinical rationale and thresholds cited elsewhere in the policy.

The reference pages that list meta-analyses, clinical series, and guideline sources are provided for clinical context and evidence support. These pages do not contain explicit coverage exclusions or additional non-medical-necessity statements within the cited reference listings.

Partial and total resurfacing or replacement procedures are considered not medically necessary for indications or conditions other than those specifically listed in the policy. The policy expressly lists contraindications and situations where resurfacing or replacement should not be performed (for example, active infection, skeletal immaturity, vascular insufficiency or significant neuromuscular compromise, Charcot joint, and AVN involving more than 50% of the femoral head for resurfacing).

Revision procedures (partial or total) are considered medically necessary only for the post-operative conditions enumerated in the revision indications section. Revision of hip replacement is not medically necessary for any other indication or condition beyond those specified; requests that do not match the listed revision indications risk denial.

Isolated head and polyethylene liner exchange (IPE) is defined as a procedure with narrow, indication-specific use. The policy states that IPE is considered medically necessary only for the specified post-operative conditions; it is not medically necessary for any other indication or condition.

Salvage procedures (for example, Girdlestone acetabuloplasty or hip arthrodesis) are considered medically necessary only when the listed salvage indications are met. The policy explicitly states that salvage procedures are not medically necessary for any other indication or condition outside those specified.

This bibliographic excerpt lists supporting literature and citations related to arthroplasty outcomes, perioperative risk factors, and guideline sources. The excerpt is a reference list and does not state additional coverage exclusions or non-medical-necessity language.

The referenced meta-analyses and clinical outcome studies cited on these pages are provided for clinical context and do not include explicit statements declaring procedures not medically necessary; they serve as supporting evidence for the policy’s clinical criteria.

Coding and Key Criteria Values

Hip Replacement/Arthroplasty CodesCPT

27125	Hemiarthroplasty, hip, partial (e.g. 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

inv-19: Age

Age limit for total hip resurfacingPatients must be age ≤64 years to meet resurfacing indications.

Policy version noteSpecified in Total Hip Resurfacing Arthroplasty indications (CMM.JT.IN.313).

Documentation sourceSee imaging and symptom criteria required in same section for eligibility.

inv-20: Failed conservative management duration

Minimum durationFailure of provider-directed non-surgical management for at least 3 months is required (≥3 months).

Exceptions3-month requirement may be waived if medical record documents why non-surgical management is inappropriate (e.g., femoral head collapse, inflammatory arthritis, advanced dysplasia).

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Prior authorization: demonstrate applicable medical necessity criteria

Prior authorization requires demonstration that all applicable medical necessity criteria are met for the requested procedure (for example, indication-specific imaging, symptom duration, and failed conservative management) before approval. The surgeon is responsible for preoperative optimization of modifiable medical and behavioral comorbidities as part of the evaluation.

Document indication-specific imaging (e.g., joint space narrowing, Tönnis grade, AVN extent).
Document symptom duration/severity and failure of non-surgical management per policy criteria.

Billing Rule

Codes table and prior authorization note — check plan

Background

Hip arthroplasty options covered in this policy include partial hip replacement (hemiarthroplasty), total hip replacement, partial and total resurfacing, and revision procedures. Indications for each option depend on imaging-confirmed pathology (for example fracture, osteoarthritis, avascular necrosis, inflammatory arthritis), symptom severity such as function-limiting pain at short distances, and documented failure of provider-directed non-surgical management for at least 3 months unless an exception is documented. Specific contraindications (for example, active infection, skeletal immaturity, AVN >50% for resurfacing) are detailed in the policy and determine when procedures are not covered.

Definitions and Clinical Terms

inv-41: Function-limiting pain definition

Definition of function-limiting painPain limiting walking to less than one-quarter mile (approximately two city blocks) and interfering with activity for at least the specified duration.

Context for symptom criteriaUsed as a required symptom threshold for resurfacing, partial, total, and revision indications where function-limiting pain is specified.

Equivalent examplesDescribed as equivalent to walking the length of a shopping mall or activity limited to two city blocks.

inv-42: Tf6nnis Grade 2-3

Tönnis Grade usedTönnis Grade 2-3 osteoarthritis is specified as an imaging finding supporting total hip replacement.

Imaging roleTönnis grading is an accepted radiographic classification indicating moderate to severe OA used in eligibility determinations.

Policy Summary

Payerevicore

PolicyHip Replacement/ Arthroplasty

Policy CodePolicy CMM-313

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review DateN/A

Key ActionObtain prior authorization demonstrating all applicable medical necessity criteria are met, including imaging, symptom duration, and failed conservative management.

SourceLink

On This Page

Leg length discrepancy

Osteolysis without eccentric wear (wear of elevated rim liner without superior wear)

ALTR from corrosion: Elevated serum metal levels diagnosing adverse local tissue reaction (ALTR) secondary to corrosion

Unexplained function-limiting pain: Function-limiting unexplained pain greater than 6 months' duration that is unresponsive to provider-directed non-surgical managementpain >6 months

Symptoms requirement: For unexplained pain indication: function-limiting pain at short distances that is unexplained, >6 months duration, and unresponsive to non-surgical management>6 months

Medical record must document the specific post-operative condition and that all subcriteria for that condition are met (e.g., symptomatic eccentric wear with well-fixed implants)

Recurrent instability/dislocation: Recurrent instability or dislocation of the replaced hip

Aseptic loosening with no options: Aseptic loosening of the replaced hip with no other practical surgical options

Inability to pursue reimplantation: Inability to pursue successful reimplantation

Procedure context: Salvage procedures are considered only when primary or revision hip replacement is not a reasonable surgical option

Documentation neededMedical record must document prior conservative treatments and reasons if exceptions are claimed.

inv-21: Avascular necrosis femoral head involvement

Allowed AVN involvement for resurfacingAvascular necrosis with less than or equal to 50% involvement of the femoral head is acceptable for resurfacing eligibility.

Contraindication thresholdAVN with greater than 50% femoral head involvement is listed as a contraindication to total hip resurfacing (not medically necessary).

Imaging requirementImaging must document extent of femoral head involvement to determine eligibility.

inv-22: BMI threshold reported in cited literature

BMI cutoff cited in literature> 45 kg/m2 is referenced as a cutoff associated with dramatically increased postoperative complications in cited study (Adhikary et al., J Arthroplasty 2016).

Use in risk stratificationBMI is referenced across multiple citations as a risk stratification measure for arthroplasty outcomes.

The codes listed in the policy (CPT 27125, 27130, 27132, 27134, 27137, 27138) are included for reference; inclusion does not imply they require prior authorization or guarantee payment. Refer to the applicable health plan for specific management and prior authorization requirements.

27125, 27130, 27132, 27134, 27137, 27138 — listed in the policy code table.

Note

Prior authorization: not specified in this excerpt (reference pages)

This reference section of the policy does not state or change prior authorization requirements; it provides supporting literature and reference material only.

Note

Prior authorization: not specified on cited reference pages

These supporting reference pages do not list or change prior authorization requirements or specific CPT/HCPCS codes; they are bibliographic in nature.

Step Therapy

Conservative management: document ≥3 months failure or documented exception

Document failure of provider-directed non-surgical management for at least three (3) months before arthroplasty unless the medical record clearly documents why non-surgical management is inappropriate (examples: femoral head collapse, inflammatory arthritis, advanced dysplasia).

If non-surgical management is inappropriate, document the clinical reason as an exception.
Surgeon should document preoperative optimization of modifiable comorbidities.

Step Therapy

Step therapy: no step therapy rules present in these excerpts

No formal step therapy rules are specified in these excerpts. Cited literature and guidance reference preoperative patient optimization and the role of physiotherapy, but the policy does not impose step therapy requirements.

Evidence citations address preoperative optimization and effects of physiotherapy, but no stepwise mandatory therapy sequence is required by the policy.

Step Therapy

Step therapy: no step therapy requirements described

No step therapy requirements are described in this excerpt of the policy; management expectations focus on documentation of failed non-surgical care and appropriate indications rather than mandated step therapy protocols.

Documentation Required

Required clinical documentation: imaging, symptoms, failed non-surgical care

Medical record must document imaging findings (e.g., joint space narrowing, Tönnis grade, AVN involvement), symptom duration and severity (function-limiting pain at short distances, impact on ADLs or employment), and failure of provider-directed non-surgical management for required durations or why such management is inappropriate.

Include imaging reports showing relevant findings (e.g., AVN extent, collapse, Tönnis grade).
Document duration of symptoms (e.g., ≥3 months) and effect on activities of daily living or employment.

Documentation Required

Clinical indication documentation: support IPE and salvage criteria

For IPE and salvage procedures, the medical record must specifically support the listed clinical indications (for example, symptomatic eccentric polyethylene wear with well-fixed implants; acute periprosthetic infection with well-fixed implants; or conditions making primary/revision arthroplasty unreasonable for salvage).

Document implant fixation and position for IPE indications.
For salvage, document the specific condition (e.g., chronic infection, inadequate bone stock) that precludes primary or revision replacement.

Note

Documentation requirements: none provided in these bibliographic chunks

These bibliographic/reference chunks do not provide additional documentation requirements beyond the policy's clinical criteria; they are literature citations rather than documentation instructions.

Note

Documentation requirements: none specified on reference pages

No documentation requirements are specified on the cited reference pages; they contain literature citations and contact information rather than policy documentation instructions.

Denial Risk

Denial triggers: non-indications that will lead to denial

Requests for partial or total hip resurfacing or hip replacement will be denied if policy non-indications are present, including avascular necrosis with greater than 50% femoral head involvement, active local or systemic infection, skeletal immaturity, vascular insufficiency or significant muscular atrophy/neuromuscular disease compromising implant stability, Charcot joint, or individuals undergoing dialysis.

AVN >50% involvement of the femoral head — resurfacing contraindication.
Active local or systemic infection.
Skeletal immaturity or conditions compromising implant stability.
Individuals undergoing dialysis are listed among exclusions.

Denial Risk

Denial risk: revision procedures outside listed indications

Revision procedures are considered not medically necessary for any indication outside the policy's specified revision criteria; requests that do not meet the listed revision indications risk denial.

Revision indications are limited to the listed post-operative conditions (e.g., aseptic loosening, periprosthetic infection, recurrent dislocation, periprosthetic fracture).
Requests outside these indications are not medically necessary per policy.

Denial Risk

Denial risk: IPE and salvage procedures outside listed indications

Isolated head and polyethylene liner exchange (IPE) and salvage procedures are considered not medically necessary for any other indications beyond those explicitly listed; requests lacking documentation that meet those specific indications risk denial.

IPE indications include symptomatic eccentric polyethylene wear with well-fixed implants, acute post-operative infection with well-fixed implants, or specified dislocation/instability conversions.
Salvage indications include chronic infection, non-ambulatory status, prohibitive comorbidities, inadequate bone stock, recurrent instability, aseptic loosening with no options, or inability to pursue reimplantation.

Note

Provider actions: bibliographic content has no denial triggers

The bibliographic section of the policy does not list specific provider actions or denial triggers; it contains literature references used by the policy.

Note

Provider actions: no authorization-specific denial triggers in references

The cited reference pages do not contain authorization-specific denial triggers; they provide supporting citations and background evidence only.

Associated symptom requirementWhen Tönnis Grade 2-3 is present, function-limiting pain for ≥3 months and failure of non-surgical management are also required unless exception documented.

inv-43: Isolated head and polyethylene liner exchange (IPE)

Definition and scopeIsolated head and polyethylene liner exchange (IPE) is a surgical exchange limited to the femoral head and polyethylene liner components.

Indicated post-operative conditionsMedically necessary for specific post-operative conditions when all associated criteria are met (e.g., eccentric polyethylene wear with symptoms and well-fixed implants; acute post-op infection with well-fixed implants; specified dislocation/instability conversions).

Procedure constraintsIPE requires well-fixed implants in acceptable position for indications like eccentric polyethylene wear or infection.

inv-44: Salvage procedures

DefinitionSalvage procedures are surgical alternatives (e.g., Girdlestone acetabuloplasty, hip arthrodesis) used when primary or revision hip replacement is not reasonable.

Examples and indicationsExamples include Girdlestone acetabuloplasty and hip joint arthrodesis; indicated for chronic infection, non-ambulatory individuals, prohibitive comorbidities, inadequate bone stock, recurrent instability, aseptic loosening with no options, or inability to pursue reimplantation.

PurposeIntended as last-resort surgical options when standard arthroplasty is not feasible or safe.

inv-45: Body Mass Index (BMI)

BMI as risk stratifierBMI is referenced as a risk stratification measure with multiple citations linking elevated BMI to worse arthroplasty outcomes.

Literature examplesCited studies include Adhikary et al. (2016) identifying >45 kg/m2 cutoff and multiple AAOS and registry reports addressing BMI and outcomes.

Clinical implicationBMI references are used to inform perioperative risk and optimization considerations in the policy notes.

inv-46: Renal disease / dialysis / transplant status

Renal disease relevanceRenal disease, dialysis, and transplant status are referenced as factors affecting complications and outcomes after total joint arthroplasty.

Evidence citedCitations include systematic reviews and comparative studies comparing dialysis versus transplant patients and outcomes (e.g., Cavanaugh et al. 2016; Li et al. 2020; Lieu et al. 2014).

Policy consequenceIndividuals undergoing dialysis are listed among conditions that may render procedures not medically necessary in policy exclusions.