CurrentFidelis CarePolicy N/A

Musculoskeletal surgery authorization matrix (hip, knee, shoulder)

Defines procedure-level authorization and allowable CPT code groupings for hip, knee, and shoulder musculoskeletal surgeries affecting Fidelis Care members; applicable to providers requesting prior authorization for these surgical procedures.

Policy Summary

PayerFidelis Care

PolicyMusculoskeletal surgery authorization matrix (hip, knee, shoulder)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 20, 2023

Next Review DateN/A

Key ActionSubmit prior authorization at the procedure level using the primary CPT code for the planned surgery; additional CPT codes that are part of the primary procedure are assumed included and do not require separate authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70+procedure and associated covered codes in the matrix

Procedure-levelauthorization granularity

Bilateral=separateauthorization exception

ED not managedmanagement exception

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered with procedure-level authorization

Covered when the request meets the procedure-level authorization and uses listed primary CPT codes.

Procedure-level authorization requirements: Authorization is provided at the procedure level using the primary CPT code listed for each surgical procedure; allowable billed groupings shown for each procedure are assumed included in that authorization and do not require separate authorization.

Includes hip, knee, and shoulder procedure groupings as listed in the matrix (see coding tables).

Musculoskeletal surgery services rendered through the Emergency Department are not managed by NIA. NIA does not prior authorize or manage the facility precertification for musculoskeletal surgery services performed in the Emergency Department.

Additional coverage notes: if any joint surgery is to be performed bilaterally on the same date of service, separate authorizations are required. The shoulder procedure listings include primary CPT codes and allowable billed groupings (for example, Shoulder Rotator Cuff Repair primary CPT = 29827; allowable billed groupings = 23410, 23412, 23420, 29827; see the matrix for full code groupings).

Coding and Allowed CPT Groupings

Hip surgery — Revision/Conversion Hip ArthroplastyCPTCovered

27134	Revision/Conversion Hip Arthroplasty (primary listed)
27132	Allowable billed grouping for Revision/Conversion Hip Arthroplasty
27137	Allowable billed grouping for Revision/Conversion Hip Arthroplasty
27138	Allowable billed grouping for Revision/Conversion Hip Arthroplasty

Hip surgery — Total/FAI/OtherCPTCovered

27130	Total Arthroplasty/Resurfacing Hip (primary listed)
S2118	Allowable billed grouping for Total Arthroplasty/Resurfacing Hip
29914	Femoroacetabular Impingement (FAI) Hip Surgery (primary listed)
29915	Allowable billed grouping for FAI Hip Surgery
29916	Allowable billed grouping for FAI Hip Surgery
29863	Hip Surgery Other (primary listed)

Knee surgery — Arthroplasty, MUA, Ligament reconstructionCPTCovered

27487	Revision Knee Arthroplasty (primary listed)
27486	Allowable billed grouping for Revision Knee Arthroplasty
27447	Total Knee Arthroplasty (TKA) (primary listed)
27446	Partial-Unicompartmental Knee Arthroplasty (UKA) (primary listed)
27438	Allowable billed grouping for UKA
27570	Knee Manipulation under Anesthesia (MUA) (primary listed)
29884	Allowable billed grouping for Knee MUA
29888	Knee Ligament Reconstruction/Repair (primary listed)
27405	Allowable billed grouping for Knee Ligament Reconstruction/Repair
27407	Allowable billed grouping for Knee Ligament Reconstruction/Repair

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Knee surgery — Meniscal proceduresCPTCovered

29880	Knee Meniscectomy/Meniscal Repair/Meniscal Transplant (primary listed)
27332	Additional covered procedure/code listed
27333	Additional covered procedure/code listed
27403	Additional covered procedure/code listed
29868	Allowable billed grouping for meniscal procedures
29881	Allowable billed grouping for meniscal procedures
29882	Allowable billed grouping for meniscal procedures
29883	Allowable billed grouping for meniscal procedures

Shoulder surgery — Arthroplasty, labral, rotator cuff, otherCPTCovered

23474	Revision Shoulder Arthroplasty (primary listed)
23473	Allowable billed grouping for Revision Shoulder Arthroplasty
23472	Total/Reverse Shoulder Arthroplasty or Resurfacing (primary listed)
23470	Partial Shoulder Arthroplasty/Hemiarthroplasty (primary listed)
29825	Frozen Shoulder Repair/Adhesive Capsulitis (primary listed)
23700	Manipulation under Anesthesia (listed as additional for Frozen Shoulder)
29806	Shoulder Labral Repair (primary listed)
23466	Allowable billed grouping for Shoulder Labral Repair
29807	Allowable billed grouping for Shoulder Labral Repair
23120	Claviculectomy (additional covered for labral repair/other shoulder)

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inv-09: Bilateral authorization requirement — Separate authorizations required when any joint surgery is performed bilaterally on the same date of service

RequirementIf any joint surgery is performed bilaterally on the same date of service, separate authorizations are required.

ScopeApplies to any joint surgery listed in this matrix (hip, knee, shoulder) when both sides are operated on the same date.

Provider consequenceFailure to obtain separate authorizations for bilateral procedures may result in claim denial or non‑payment.

Submission noteSubmit distinct prior authorization requests for each side when procedures are bilateral on the same date of service.

Provider Actions and Authorization Requirements

Prior Authorization

Procedure-level prior authorization

Prior authorization is required at the procedure level using the listed primary CPT codes. Multiple CPT codes that are part of the same surgical procedure are assumed to be included with the primary request and, when billed in combination, do not require a separate authorization.

Authorization is provided at the procedure level — submit using the primary CPT code for the planned surgery.
Include additional CPT codes that are part of the same operative episode; these are considered part of the primary authorization and do not require separate requests.

Prior Authorization

Procedure-level submission

Submit prior authorization requests at the procedure level using the primary CPT code for the planned surgery. Ensure documentation supports the listed primary code and any allowable billed groupings.

Primary CPT code must be used as the authorization request code.
Allowable billed groupings (additional CPTs listed under each procedure) are assumed included when performed together.

Denial Risk

Bilateral authorization requirement (provider impact)

If any joint surgery is to be performed bilaterally on the same date of service, separate authorizations are required for each side.

Failure to obtain separate authorizations for bilateral joint surgeries performed on the same date of service may result in claim denial or delayed payment.
Obtain and document distinct prior authorization numbers for each bilateral procedure.

Note

Provider action note

Musculoskeletal surgery services rendered through the Emergency Department are not managed by National Imaging Associates (NIA). NIA does not prior authorize or manage facility precertification for musculoskeletal surgery services.

Emergency Department musculoskeletal surgery services are excluded from NIA management.
Facility precertification for musculoskeletal surgery is not handled by NIA — follow facility-specific precertification procedures as applicable.

Definitions

inv-15: Procedure-level authorization — definition: an authorization tied to the primary surgical procedure CPT code; associated CPT codes listed as allowable...

DefinitionProcedure-level authorization: an authorization tied to the primary surgical procedure CPT code; associated CPT codes listed as allowable billed groupings are considered part of that authorization.

What to submitSubmit prior authorization using the primary CPT code for the planned surgery; allowable billed groupings and additional procedures listed in the matrix are assumed included and do not require separate authorization.

Primary CPT codes (examples)Includes primary procedure codes such as 27134 (revision/conversion hip), 27487 (revision knee), 23474 (revision shoulder) — see matrix for full list.

Included codesAllowable billed groupings (associated CPT codes) shown for each procedure are considered part of the primary authorization and should not be submitted as separate authorizations.

PurposeStandardizes prior authorization handling for hip, knee, and shoulder musculoskeletal surgeries by authorizing at the procedure (primary CPT) level.

OpenPayer

Musculoskeletal surgery authorization matrix (hip, knee, shoulder)

Coverage Criteria

Coding and Allowed CPT Groupings

Provider Actions and Authorization Requirements

Background

Definitions