CurrentevicorePolicy CMM-311

Knee Replacement/Arthroplasty

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Coverage guidelines for partial, total, and revision knee replacement procedures and related definitions and general guidance for clinicians and medical directors administering Cigna health benefit plans.

Policy Summary

Payerevicore

PolicyKnee Replacement/Arthroplasty

Policy CodePolicy CMM-311

Change TypeNo material changes

Effective DateMar 7, 2026

Next Review Date

Key ActionDocument that ALL applicable criteria are met, including imaging severity, symptoms, exam, and failure of provider-directed non-surgical management for the required duration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Part 4document segment position

3 monthsrequired non-surgical management

>90°required arc of motion

KL III/IVradiographic severity

ABI <0.5

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CurrentevicorePolicy CMM-311

Knee Replacement/Arthroplasty

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Policy Summary

Payerevicore

PolicyKnee Replacement/Arthroplasty

Policy CodePolicy CMM-311

Change TypeNo material changes

Effective DateMar 7, 2026

Next Review Date

Key ActionDocument that ALL applicable criteria are met, including imaging severity, symptoms, exam, and failure of provider-directed non-surgical management for the required duration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Part 4document segment position

3 monthsrequired non-surgical management

>90°required arc of motion

KL III/IVradiographic severity

ABI <0.5

vascular insufficiency exclusion

Coverage Criteria

Medical necessity determination

Determination of medical necessity is made on a case-by-case basis and considers conservative management and relevant imaging and procedure guidance.

Medical necessity determination: The performance of knee replacement (partial or total) requires case-by-case medical necessity determination considering: (1) the terms of the applicable benefit plan in effect on the date of service; (2) applicable laws and regulations; (3) relevant collateral materials including coverage policies; and (4) the specific facts of the situation.

Providers should reference advanced imaging indications in MS-12, MS-16, and MS-25 and procedure indications in CMM-312 as applicable.

Patellofemoral unicompartmental replacement following total knee replacement — Indications

Considered medically necessary when ALL of the following are met:

Patellofemoral after TKR: Procedure is performed to manage protracted anterior knee pain and/or mechanical symptoms attributed to the patellofemoral joint following a total knee replacement when patellar replacement was NOT performed at the index procedure; physical exam demonstrates BOTH intact, stable ligaments AND knee arc of motion (full extension to full flexion) >90°; symptoms include BOTH function-limiting pain at short distances for at least three (3) months AND loss of knee function interfering with age-appropriate activities of daily living and/or demands of employment; and failure of provider-directed non-surgical management for at least three (3) months OR documented reason why non-surgical management is inappropriate.

Total knee replacement — Indications

Considered medically necessary for ANY of the following when ALL associated criteria are met:

Indications list: Fracture of the distal femur where imaging shows fracture and conservative management or fixation is not reasonable; OR Osteoarthritis (uni-, bi-, or tricompartmental) or avascular necrosis (AVN) with imaging or arthroscopic findings demonstrating severe disease (Kellgren-Lawrence Grade III or IV radiographic OR Outerbridge Grade IV arthroscopic AND not a candidate for joint-sparing OR Modified Outerbridge Grade IV MRI AND not a candidate for joint-sparing) OR AVN of the femoral condyles/proximal tibia. For OA/AVN indications: symptoms must include function-limiting pain at short distances for at least three (3) months and loss of knee function interfering with ADLs or employment; failure of provider-directed non-surgical management for at least three (3) months OR documented exception; and the surgeon should optimize reasonably modifiable medical and behavioral health comorbidities preoperatively.

Revision of knee replacement — Indications (alternate entry)

Revision of a prior partial or total knee replacement is considered medically necessary when ANY of the following post-operative conditions are present:

Revision indications (alternate entry): Patellar fracture or dislocation; aseptic loosening; periprosthetic infection; periprosthetic fracture; implant fracture or component failure; post-operative stiffness >12 weeks when BOTH manipulation is unsafe AND components are well-positioned, well-fixed, and appropriately-sized; post-operative stiffness due to component sizing or positioning; instability of the knee; clinically significant, symptomatic limb malalignment due to existing component position; function-limiting pain at short distances unexplained for >6 months and unresponsive to provider-directed non-surgical management; and when revising from a partial to total replacement, Kellgren-Lawrence Grade IV radiographic findings in nonreplaced compartments.

Revision of Knee Replacement Indications

Revision of knee replacement is considered medically necessary when ANY of the following post-operative conditions are present:

Revision Indications: patellar fracture or dislocation; aseptic loosening; periprosthetic infection; periprosthetic fracture; implant fracture or component failure; post-operative stiffness for more than 12 weeks when manipulation is unsafe and components are well-positioned, well-fixed, and appropriately-sized; post-operative stiffness due to component sizing or positioning; instability of the knee; clinically significant, symptomatic limb malalignment due to existing component position; function-limiting pain at short distances, unexplained, greater than six (6) months duration, and unresponsive to provider-directed non-surgical management; and when revising from a partial (unicompartmental) knee replacement to a total joint replacement, Kellgren-Lawrence Grade IV radiographic findings in the nonreplaced compartments.N/A

List taken verbatim from policy

Isolated Polyethylene Liner Exchange (IPE) Indications

IPE is considered medically necessary for ANY of the following post-operative conditions when ALL of the associated criteria have been met:

IPE Indications: Eccentric polyethylene wear and osteolysis with imaging confirming BOTH progressive osteolysis AND well-fixed implants in acceptable position; OR Catastrophic polyethylene failure (including post fracture, locking mechanism failure, severe polyethylene wear) with BOTH presence or risk for metallosis and polyethylene liner fracture AND absence of component loosening or malalignment; OR Acute post-operative joint infection (periprosthetic or hematogenous) with well-fixed implants; OR Stiffness following total knee replacement (flexion contracture >15° with flexion limited to <90°) presenting later than three (3) months from the index procedure with persistent restricted range of motion despite BOTH physical therapy AND manipulation under anesthesia; OR Instability without component malrotation or malalignment.ALL associated criteria per indication must be met

Policy requires ALL criteria for each listed IPE indication

Any coverage exclusions contained in a customer's specific benefit plan document supersede this coverage policy and may exclude services. Coverage determinations require consideration of: (1) the terms of the applicable benefit plan in effect on the date of service; (2) applicable laws and regulations; (3) relevant collateral materials including coverage policies; and (4) the specific facts of the particular situation.

The policy lists explicit exclusion conditions under which partial or total knee replacement are considered not medically necessary. Examples include: Grade IV patellofemoral osteoarthritis involving the lateral patella/trochlea (when medial/lateral unicompartmental planned), Grade III/IV medial or lateral compartment OA (when patellofemoral unicompartmental planned), patellar malalignment (e.g., increased Q angle or TT‑TG ≥20 mm, tibial/femoral shaft deformity, radiographic subluxation), flexion contracture >15°, excessive valgus/varus deformity beyond the stated thresholds, Charcot joint, inflammatory arthropathy, active local or systemic infection, vascular insufficiency (ankle brachial index <0.5), significant muscular atrophy or severe neuromuscular disease that would compromise implant stability or recovery, and individuals undergoing dialysis.

Arthroscopic or open abrasion arthroplasty procedures of the knee tibial plateau(s), patella, and/or femoral condyle(s), with or without debridement and partial synovectomy, are considered not medically necessary for the treatment of symptomatic knee osteoarthritis.

The bibliography section provides supporting literature and reference citations; it does not itself state additional explicit coverage exclusions.

This coverage policy is intended to guide administrative coverage determinations and is not a treatment recommendation. Clinical decisions should be made by treating clinicians using clinical judgment and current standards of care.

Partial or total knee replacement is considered not medically necessary for any other indication or condition not listed in the policy, or when any of the listed exclusion conditions are present.

Revision of knee replacement is considered not medically necessary for any other indication or condition beyond the specific revision indications enumerated in the policy.

Isolated polyethylene liner exchange (IPE) is considered not medically necessary for any other indication or condition beyond the specific IPE indications and the requirement that ALL associated criteria for those indications be met.

The bibliography lists supporting literature and reference citations used in developing the policy. This segment presents references and does not itself make not‑medically‑necessary determinations.

Coding

Referenced code lists and cross-referencesmixed

No codes listed

Referenced procedure codesCPT

CPT® 27442

trochleoplasty (referenced for trochlear dysplasia in patellar instability; see CMM-312)

Procedure CPT Codes listedCPT

27438	Arthroplasty, patella; with prosthesis
27440	Arthroplasty, knee, tibial plateau
27441	Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
27443	Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy
27445	Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)
27446	Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
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

Cartilage lesion size (Outerbridge Grade II vs III) — size thresholds

Outerbridge Grade II thresholdFragmentation and fissuring < 1 cm^2

Outerbridge Grade III thresholdFragmentation and fissuring > 1 cm^2

Clinical useDistinguishes smaller (<1 cm^2) versus larger (>1 cm^2) chondral lesions to inform repair versus replacement decisions

Ankle Brachial Index (ABI) — <0.5 vascular insufficiency exclusion

Ankle Brachial Index (ABI) exclusion thresholdABI < 0.5 indicates vascular insufficiency and is an exclusion to arthroplasty

ContextVascular insufficiency listed among conditions that render partial or total knee replacement not medically necessary

Provider Actions / Prior Authorization

Note

Consider benefit plan terms and laws for coverage decisions

Coverage decisions require consideration of the applicable benefit plan terms, any applicable laws/regulations, relevant collateral materials (including coverage policies), and the specific facts of the situation; the member's benefit plan document supersedes this policy when in conflict.

Prior Authorization

Prior authorization must document that criteria are met

When requesting prior authorization, document that ALL applicable criteria for the selected indication are met, including imaging or arthroscopic severity, required symptoms and functional limitations, physical exam findings, and failure of provider-directed non-surgical management for the required duration (or a documented exception).

Imaging/arthroscopic severity (e.g., Kellgren‑Lawrence Grade III/IV or Outerbridge Grade IV) as specified for the indication
Symptoms: function-limiting pain at short distances and loss of knee function interfering with ADLs/employment
Physical exam findings (e.g., knee stability; knee arc of motion >90° for partial or patellofemoral procedures)

Definitions

Kellgren-Lawrence Grading System — radiographic OA grading I-IV

Grade IDoubtful narrowing of joint space and possible osteophytic lipping

Grade IIDefinite osteophytes and possible narrowing of joint space

Grade IIIModerate multiple osteophytes, definite narrowing of joint space, some sclerosis, and possible deformity of bone contour

Grade IVLarge osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity of bone contour

Outerbridge / Modified Outerbridge Classification — cartilage injury Grade I-IV

Grade ISoftening with swelling

Grade II

Background

Knee arthroplasty refers to surgical replacement, remodeling, or realignment of the knee joint and includes partial (unicompartmental) procedures (medial, lateral, or patellofemoral), total knee replacement (replacement of one or more compartments), and revision procedures performed for failure or complications of a prior knee replacement.

Policy Summary

Payerevicore

PolicyKnee Replacement/Arthroplasty

Policy CodePolicy CMM-311

Change TypeNo material changes

Effective DateMar 7, 2026

Next Review Date

Key ActionDocument that ALL applicable criteria are met, including imaging severity, symptoms, exam, and failure of provider-directed non-surgical management for the required duration.

SourceLink

On This Page

Action for providersDocument ABI when vascular disease suspected; ABI <0.5 should prompt non-coverage consideration per policy

Q angle — 15° males / 20° females (patellar malalignment exclusion)

Q angle threshold (males)15° in males (increased Q angle is evidence of patellar malalignment)

Q angle threshold (females)20° in females (increased Q angle is evidence of patellar malalignment)

Policy implicationPatellar malalignment syndromes defined by increased Q angle are listed as exclusions for unicompartmental procedures

TT-TG distance — 20 mm (patellar malalignment exclusion)

TT-TG distance thresholdTT-TG (tibial tuberosity–trochlear groove) distance ≥ 20 mm indicates patellar malalignment

Clinical roleTT-TG ≥20 mm is cited as evidence of patellar malalignment syndrome and an exclusion for unicompartmental replacement

Provider actionInclude TT-TG measurement in imaging reports when patellofemoral pathology suspected

Flexion contracture — >15° exclusion for partial knee replacement

Flexion contracture exclusion threshold> 15° flexion contracture (exclusion for partial knee replacement; cited in IPE stiffness criteria as >15°)

Related IPE contextFlexion contracture >15° with flexion limited to <90° is listed under IPE stiffness indication criteria

ImplicationSignificant fixed flexion contracture excludes candidacy for unicompartmental procedures per policy

Fixed deformity thresholds — valgus/varus degree thresholds for partial and total knee replacement

Partial knee replacement deformity thresholdsValgus > 20° or Varus > 15° are exclusions for unicompartmental (partial) knee replacement

Total knee replacement fixed deformity threshold> 30° fixed varus or valgus that is not amendable to surgical correction is an exclusion for total knee replacement

Clinical implicationFixed coronal deformities beyond these degrees indicate non-candidacy or need for total rather than partial arthroplasty

Failure of provider-directed non-surgical management for at least 3 months OR clear documentation why non-surgical care is inappropriate

Billing Rule

Listed arthroplasty and revision CPT codes may require prior auth

The CPT codes listed in the policy (e.g., 27438, 27440, 27441, 27443, 27445, 27446, 27447, 27486, 27487) may require prior authorization per the applicable health plan; inclusion in the table does not guarantee coverage or payment.

Examples: 27438, 27440, 27441, 27443, 27445, 27446, 27447, 27486, 27487
Refer to the applicable health plan for management and prior authorization details

Note

No explicit prior authorization rules in this extract

This extract does not provide an explicit prior authorization process, code list, or step-by-step authorization rules — check the member's health plan for specific prior authorization requirements and processes.

Note

No prior authorization instructions provided here

No prior authorization instructions are present within this excerpt; providers must consult the applicable health plan or certificate of coverage for prior authorization procedures and managed code lists.

Step Therapy

Non-surgical management is required conservative care prior to arthroplasty

Non-surgical management is defined as provider-directed conservative care (e.g., activity modification, weight loss, supervised physiotherapy, medications, assistive devices, and/or intraarticular injections) and is identified as relevant conservative care prior to surgical arthroplasty.

Examples: activity modification, weight loss, supervised physiotherapy and therapeutic exercises, prescription/nonprescription medications, assistive devices, intraarticular injections

Prior Authorization

Document ≥3 months of failed non-surgical management (or exception)

Providers must show failure of provider-directed non-surgical management for at least three (3) months for most indications, or document clearly why non-surgical management is inappropriate.

Document duration of conservative care and specific treatments attempted
If an exception is claimed, include clear medical record documentation explaining why non-surgical care was inappropriate

Step Therapy

Attempt specific conservative treatments before some procedures

For certain indications (e.g., post-operative stiffness or other listed IPE/revision indications), required conservative interventions such as physical therapy, manipulation under anesthesia, or other specified non-surgical measures must have been attempted or considered prior to surgery.

Example (IPE stiffness): presentation later than 3 months from index procedure and persistent restricted ROM despite both physical therapy and manipulation under anesthesia
Document which conservative interventions were attempted and their timing relative to the requested procedure

Note

No formal step therapy pathways described

No step therapy requirements are described in this bibliography portion; the policy does not list formal step-therapy pathways beyond required conservative care for indications.

Note

No step therapy requirements in bibliography pages

No step therapy requirements appear elsewhere in these bibliography pages; confirm with the member's plan for any plan-specific step edits.

Documentation Required

Reference cross‑referenced imaging and procedure guidance in documentation

Medical necessity determinations are made case-by-case; providers should reference the advanced imaging policies MS-12, MS-16, and MS-25 and related procedural guidance (e.g., CMM-312) when preparing documentation for authorization or review.

Cross-reference advanced imaging indications in MS-12, MS-16, MS-25
Refer to CMM-312 for related procedural indications (e.g., trochleoplasty/CPT 27442)

Documentation Required

Required clinical documentation for medical necessity

Clinical documentation must demonstrate imaging or arthroscopic findings meeting specified severity (e.g., Kellgren‑Lawrence Grade III/IV or Outerbridge Grade IV), appropriate physical exam findings (stability, required arc of motion), symptom duration and functional limitation, and failure of provider‑directed non‑surgical management or a documented reason why it is inappropriate.

Imaging/arthroscopy: Kellgren‑Lawrence Grade III or IV, Outerbridge/Modified Outerbridge Grade IV where required
Exam: knee stability and, where specified, knee arc of motion >90° (partial and patellofemoral indications)
Symptoms: function‑limiting pain at short distances for ≥3 months and loss of knee function interfering with ADLs/employment
Conservative care: failed provider‑directed non‑surgical management for ≥3 months or documented exception

Documentation Required

Support the specific listed indication with targeted documentation

Documentation should specifically support the listed indication (for example, periprosthetic infection, aseptic loosening, implant fracture, eccentric polyethylene wear with progressive osteolysis and well‑fixed implants) and demonstrate that ALL associated criteria for that indication are met (IPE requires ALL associated criteria).

For IPE: demonstrate BOTH progressive osteolysis and well‑fixed implants for eccentric wear; for catastrophic failure show criteria regarding metallosis and absence of loosening
For revisions: provide imaging and clinical evidence supporting the named revision indication (e.g., infection, loosening, fracture, instability)

Note

Bibliography supports guidance but does not add documentation rules

This section of the document contains bibliographic references that support clinical guidance but does not itself specify additional authorization documentation requirements; use cited literature for clinical context while meeting the policy's explicit documentation items.

Note

No extra documentation requirements in these reference pages

No additional documentation requirements are specified in the referenced bibliography pages; adhere to the policy's stated documentation expectations and the member's plan requirements.

Denial Risk

Benefit plan terms and law govern coverage; plan prevails on conflict

Determinations are governed by the terms of the member's applicable benefit plan and applicable laws; when conflict exists the member's benefit plan document prevails and may result in denial if exclusions apply.

Denial Risk

Exclusion‑based conditions can trigger denial

Procedures are at risk for denial when excluded conditions listed in the policy are present (examples include active infection, vascular insufficiency—ABI <0.5, inflammatory arthropathy, severe neuromuscular disease, or joint instability not amendable to correction).

Vascular insufficiency defined as ankle brachial index <0.5
Active local or systemic infection
Inflammatory arthropathy, Charcot joint, significant muscular atrophy, or neuromuscular disease compromising implant stability
Joint instability not amendable to surgical correction; specified deformity thresholds for partial/total procedures

Denial Risk

Unsupported revision requests may be denied

Revision requests that do not meet one of the listed revision indications are at risk for denial because the policy states revision of knee replacement is not medically necessary for any other indication or condition.

Ensure documentation demonstrates a listed revision indication (e.g., infection, aseptic loosening, periprosthetic fracture, implant failure, instability, stiffness meeting criteria, unexplained pain >6 months unresponsive to conservative care)

Denial Risk

IPE requests lacking ALL indication criteria risk denial

Isolated polyethylene liner exchange (IPE) requests that do not meet ALL associated IPE criteria are at risk for denial because IPE is considered not medically necessary for any other indication or condition.

For eccentric wear and osteolysis: document BOTH progressive osteolysis and well‑fixed implants in acceptable position
For catastrophic failure: document BOTH risk/presence of metallosis and absence of component loosening or malalignment
For stiffness: document presentation later than 3 months and failure of both PT and manipulation under anesthesia

Note

No explicit auth/denial triggers in bibliography segment

No explicit authorization or denial triggers are present in this bibliography segment; rely on the policy criteria and the member's benefit plan for authorization/denial decisions.

Note

No auth/denial triggers in bibliography pages

No authorization or denial triggers are identified in these bibliography pages; authorization and denial are determined by the policy criteria and the applicable plan terms.

Fragmentation and fissuring < 1 cm^2

Grade IIIFragmentation and fissuring > 1 cm^2

Grade IVSubchondral bone exposed

Non-Surgical Management — definition and examples (activity modification, PT, injections, weight loss)

DefinitionProvider-directed non-surgical treatments for lower extremity joint pain including activity modification, weight loss, supervised physiotherapy, medications, assistive devices, and intraarticular injections

ExamplesRelative rest/activity modification; supervised physiotherapy modalities and therapeutic exercises; prescription and nonprescription medications; assistive devices; intraarticular injections

Policy roleFailure of provider-directed non-surgical management for ≥3 months is generally required before arthroplasty

Partial Knee Replacement — definition (unicompartmental)

DefinitionSurgical reconstruction or replacement of one joint surface of the knee due to unicompartmental involvement (medial, lateral, or patellofemoral)

ScopeIncludes medial, lateral, or patellofemoral unicompartmental procedures

Policy implicationIndications require isolated-compartment severe disease (e.g., Kellgren-Lawrence or Outerbridge Grade IV) and preserved stability and motion

Total Knee Replacement — definition (complete joint replacement)

DefinitionSurgical reconstruction or replacement of the entire knee joint for uni-, bi-, or tricompartmental disease

Indication severityOften supported by Kellgren-Lawrence Grade III/IV radiographic findings or Outerbridge Grade IV arthroscopic findings

Clinical noteRequires failure of provider-directed non-surgical management for ≥3 months for most OA/AVN indications

Revision of Knee Replacement — definition (reconstruction/replacement due to failure/complication)

DefinitionSurgical reconstruction or replacement due to failure or complications of a previous knee replacement (partial or total)

Included scenariosRevision may be for aseptic loosening, infection, periprosthetic fracture, implant failure, instability, malalignment, or unexplained persistent pain

Policy requirementRevision indications listed require specific post-operative conditions to be met per policy

Prosthesis — definition (artificial device replacing structural element)

DefinitionAn artificial device used to replace a structural element within a joint to improve and enhance function

ContextApplied to prosthetic components used in partial, total, and revision knee arthroplasty

Policy relevanceProsthesis status (well-fixed, well-positioned) is a criterion in IPE and revision determinations

Kellgren-Lawrence Grade III/IV — radiographic severity cited supporting arthroplasty

Kellgren-Lawrence Grade III/IV roleRadiographic severity (Grade III or IV) is cited in policy as supporting indications for total or partial arthroplasty

Use in criteriaKellgren-Lawrence Grade IV specifically supports unicompartmental indications; Grade III or IV support total knee indications

DocumentationImaging demonstrating Grade III/IV should be included in clinical documentation for consideration

Revision of knee replacement — includes revision of TKR, UKA-to-UKA, or to TKR as described

Revision scopeRevision includes revision of TKR, revision of UKA-to-UKA, or revision of UKA-to-TKR as described in policy

ImportancePolicy explicitly defines revision to include these scenarios when assessing medical necessity

Clinical implicationRequests for revision should specify which prior prosthesis is being revised (partial vs total) and the indication

Isolated Polyethylene Liner Exchange (IPE) — definition and indication context

DefinitionExchange of the polyethylene liner without revision of well-fixed components

Indication contextConsidered medically necessary for specified post-operative conditions when ALL associated criteria are met (e.g., eccentric polyethylene wear with progressive osteolysis and well-fixed implants)

Policy requirementAll listed criteria for the specific IPE indication must be satisfied for medical necessity

Unicompartmental knee arthroplasty (UKA) — definition and cited study context

DefinitionSurgical replacement of only one compartment of the knee (medial, lateral, or patellofemoral)

Evidence contextPolicy references multiple studies comparing UKA survivorship, indications, and outcomes versus TKA

Indication nuanceUKA is appropriate for isolated-compartment severe disease with preserved stability and adequate range of motion

Total knee arthroplasty (TKA) — definition and cited literature on outcomes and survivorship

DefinitionComplete replacement of the knee joint (total knee arthroplasty)

Outcomes literatureCited literature addresses outcomes, complications, and factors affecting survivorship such as obesity and comorbid conditions

Indication criteriaOften supported by Kellgren-Lawrence Grade III/IV or Outerbridge Grade IV findings and failure of non-surgical management