CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Total Hip Arthroplasty

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Defines Kaiser Permanente Washington clinical review and medical necessity criteria for total hip arthroplasty (including inpatient vs ambulatory level of care, indications such as degenerative hip disease, avascular necrosis, inflammatory arthritis, revisions, and contraindications), required documentation, and applicable CPT codes.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Total Hip Arthroplasty

Policy CodePolicy N/A

Change TypeRevised (documentation, level-of-care adoption) & Clarifications

Effective DateJun 1, 2023

Last ReviewAug 5, 2025

Next Review DateN/A

Key ActionProvide last 6 months of clinical notes, relevant imaging within 12 months, documentation of conservative care trials and optimization efforts (BMI, A1c, nicotine) when submitting requests.

SourceLink

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CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Total Hip Arthroplasty

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Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Total Hip Arthroplasty

Policy CodePolicy N/A

Change TypeRevised (documentation, level-of-care adoption) & Clarifications

Effective DateJun 1, 2023

Last ReviewAug 5, 2025

Next Review DateN/A

Key ActionProvide last 6 months of clinical notes, relevant imaging within 12 months, documentation of conservative care trials and optimization efforts (BMI, A1c, nicotine) when submitting requests.

SourceLink

POLICY UPDATE CHANGES

MPC approved updates to the documentation requirements for Arthritis, Degenerative Disease section effective 01/01/2026 (60-day notice).

MPC approved to adopt medical necessity criteria for Total Hip Arthroplasty for non-Medicare, effective 06/01/2023.

Clarified Level of Care Requirement for Medicare and Non-Medicare Members (05/16/2023).

Added clarification on Medicare IPO list update effective 01/01/2022 (02/06/2023).

6Core Indication Categories

6Key Optimization Criteria

6CPT Codes Listed

Coverage Summary

Background: Total hip arthroplasty (THA) (also called total hip replacement) is performed to relieve severe pain and restore function in patients with advanced hip joint disease by replacing damaged bone and cartilage with a prosthetic implant. This Kaiser Permanente policy uses clinical and Medicare/commercial criteria to determine appropriate use and level of care for THA, aiming to ensure safety and efficacy.

Scope and status: This document (Clinical Review Criteria Total Hip Arthroplasty) defines Kaiser Permanente Washington clinical review and medical necessity criteria for total hip arthroplasty, including indications, inpatient vs ambulatory level of care, required documentation, and applicable CPT codes. Payer: Kaiser Permanente. Policy title: Clinical Review Criteria Total Hip Arthroplasty. Effective date: 2023-06-01. Last review: 2025-08-05. Coverage stance: covered_with_criteria.

Key thresholds

Radiographic recencyImaging performed within the prior 12 months

Physical therapy trialSupervised PT within last 12 months; attendance >75% of sessions, minimum of 3 visits; flexibility and strengthening exercises

BMIPreferably < 35; if >35 document optimization efforts over 3–6 months (sustained weight loss or active weight‑loss/exercise program and formal nutritional counseling); >40 is a relative contraindication

HbA1cNo diabetes or A1c < 7.5 preferred; A1c >7.5 requires active medical management and reduction over 3–6 months; A1c >8.0 is a relative contraindication

Nicotine/tobacco abstinenceMust be in cessation program and nicotine/tobacco‑free for minimum 30 days prior to surgery OR have a 90% reduction in use

Anti-inflammatory medication requirement (effective 2026-01-01)Continuous use for a minimum of 6 weeks including BOTH acetaminophen and an NSAID (oral preferred) unless contraindicated

Core Indication Categories6

CPT Codes Listed6

Medical Necessity Criteria (by indication and scenario)

Level of Care — Inpatient Total Hip Arthroplasty (Non-Medicare)

To be approved as inpatient; ONE of the following criteria must be met:

ANY of the following

Bilateral total hip
Coexisting neurologic condition (such as multiple sclerosis, hemiparesis, severe Parkinson's, or other neurologic conditions) where the expected length of stay is planned to be longer than 2 midnights
Meets indications on the Elective Surgical Procedure Level of Care policy

If patient qualifies for inpatient status, must also meet general medical necessity criteria (see General Medical Necessity block)

General Medical Necessity — All Total Hip Arthroplasties (ambulatory & inpatient)

Coding

Applicable CPT Codes (considered medically necessary when criteria met)CPTCovered

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; (description truncated in source)
27138	Revision of total hip arthroplasty; femoral component only, with or without allograft
27236	(code listed in policy; description truncated in source)

Provider Actions & Operational Notes

Documentation Required

Submit supporting documentation for medical necessity

Provide last 6 months of clinical notes from requesting provider/specialist, relevant imaging within 12 months, documentation of conservative care trials, optimization efforts (BMI, A1c, nicotine cessation), and rationale if conservative therapy inappropriate.

Last 6 months of clinical notes from requesting provider &/or specialist
Relevant imaging performed within the prior 12 months
Documentation of conservative care trials (medication, PT, injections)
Documentation of optimization efforts for BMI, HbA1c, and nicotine/tobacco cessation
If conservative therapy is not appropriate, a documented rationale explaining the exemption

Prior Authorization

Preauthorization / Level of Care review

Background

Purpose and intent: Total hip arthroplasty (THA) is most often performed for severe pain and functional limitation from osteoarthritis and other hip joint disorders (rheumatoid arthritis, post‑traumatic arthritis, avascular necrosis, fracture, etc.). The policy’s intent is to ensure appropriate use and level of care for THA by applying clinical medical‑necessity criteria and aligning with Medicare and commercial requirements where applicable (including Medicare LCD/LCA guidance and an inpatient‑only code list for Medicare members).

This policy outlines: indications (degenerative hip disease, avascular necrosis, inflammatory arthritis, revisions, conversions, acute fracture), level‑of‑care rules for inpatient approval for non‑Medicare members, optimization requirements before elective surgery (BMI, HbA1c, nicotine cessation), documentation and conservative care requirements (imaging recency, medication, injections, physical therapy), and applicable CPT codes.

Definitions: Tonnis Grade — Radiographic classification of hip osteoarthritis severity (Grade 2 or 3 indicates moderate to severe OA).

Medicare Determinations

Determination	Details
Total Hip Arthroplasty (LCD L36573)	Effective 2022-01-01
Billing and Coding: Total Hip Arthroplasty (LCA A57684)	No effective date listed in source
Total Hip Arthroplasty (general applicable CPT codes)	CPT codes listed include 27130, 27132, 27134, 27137, 27138, 27236 (considered medically necessary when criteria met)

Revision History

2026-01-01medication_duration_changeLatest

Effective Jan 1, 2026, conservative management medication requirement changed to continuous use of anti-inflammatory medication for a minimum of 6 weeks, including BOTH acetaminophen and a non-steroidal anti-inflammatory drug (oral preferred) unless contraindicated.

2023-06-01adoption_non-medicare

MPC approved adoption of medical necessity criteria for Total Hip Arthroplasty for non-Medicare members, merging Inpatient Total Joint - Level of Care with the medical necessity policy (60-day notice).

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Total Hip Arthroplasty

Policy CodePolicy N/A

Change TypeRevised (documentation, level-of-care adoption) & Clarifications

Effective DateJun 1, 2023

Last ReviewAug 5, 2025

Next Review DateN/A

Key ActionProvide last 6 months of clinical notes, relevant imaging within 12 months, documentation of conservative care trials and optimization efforts (BMI, A1c, nicotine) when submitting requests.

SourceLink

On This Page

All total hip arthroplasties are medically necessary when the following criteria are met:

ALL of the following

Member has advanced joint disease demonstrated by limited range of motion (ROM), antalgic gait, and pain in hip joint with passive ROM on physical examination
Pain and functional disability that interferes with activities of daily living (ADLs) from osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the hip joint

Arthritis / Degenerative Hip Disease

Must meet general criteria above AND both radiographic criteria and conservative management failure:

ALL of the following

ONE of
- Subchondral cysts
- Subchondral sclerosis
- Joint subluxation
- Periarticular osteophytes
- Bone on bone articulation
- Tonnis Grade 2 or 3 Osteoarthritis
- Moderate/Severe joint space narrowing
ALL of the following
- Continuous anti-inflammatory medication trial (per policy change effective 01/01/2026): continuous use for a minimum of 6 weeks including BOTH acetaminophen and a non-steroidal anti-inflammatory drug unless contraindicatedAnti-inflammatory medication: continuous 6 weeks (effective 2026-01-01)
  Previously 2–3 weeks
- Intra-articular corticosteroid injection as appropriate
- Trial of Physical Therapy in the last 12 months with supervised PT, attendance at >75% of sessions, minimum of 3 visits, including flexibility and muscle strengthening exercisesPT attendance >75% and minimum 3 visits within last 12 months

Elective Surgery Optimization Requirements (applies to standard elective surgery)

All patients meeting clinical criteria must also meet ALL of the following optimization criteria (exceptions and case-by-case review described):

BMI < 35; if BMI > 35, documentation of optimization efforts over 3–6 months (sustained weight loss OR documented active participation in a weight loss/exercise program) and formal nutritional counseling; BMI > 40 is a relative contraindication but may be reviewed case-by-caseBMI preferably < 35; BMI >35 requires optimization over 3–6 months; BMI >40 relative contraindication

No diabetes, or diabetes with HbA1c < 7.5 (with heart disease threshold not lower than 7.5); members with A1c > 7.5 must demonstrate active medical management and reduction in A1c over 3–6 months; A1c > 8.0 is a relative contraindication but may be reviewed case-by-caseHbA1c < 7.5 preferred; A1c >7.5 requires active management; A1c >8.0 relative contraindication

Nicotine/tobacco users must be actively involved in a cessation program and be nicotine/tobacco-free for a minimum of 30 days prior to surgery OR have a 90% reduction in use; lack of change is a relative contraindication but may be reviewed case-by-caseNicotine/tobacco-free for minimum 30 days or 90% reduction

Avascular Necrosis

Patients with avascular necrosis may proceed directly with surgery when imaging evidence is present:

Radiographic or MRI evidence (plain film or MRI) showing avascular necrosis / bone infarct

Inflammatory Arthritis (e.g., RA, Psoriatic, Spondyloarthropathy, gout, lupus, hemophilia-related arthritis)

May be considered when nonsurgical options exhausted and imaging shows moderate/severe disease:

Patient actively being followed by Rheumatology and has been judged to have exhausted all nonsurgical options including DMARDs

Radiographic or imaging evidence (performed within the prior 12 months) of moderate/severe osteoarthritis with at least one of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, bone-on-bone articulation, moderate/severe joint space narrowingImaging performed within the prior 12 months

Reasonable restriction of activities (activity or weightbearing modification or use of an assistive device); if conservative therapy not appropriate, medical record must document why (exemptions: rapid progression, progressive flexion contracture, medical or social factors precluding conservative treatment)

Revision/Replacement of Previous Arthroplasty

Indications for revision/replacement (medically necessary when criteria met):

Aseptic loosening of one or more prosthetic components confirmed by imaging

Presence of ANY of the following: bearing surface wear leading to symptomatic synovitis or local bone/soft tissue reaction; periprosthetic fracture; component instability; fracture/mechanical failure/recall of a prosthetic component; progressive or substantial periprosthetic bone loss; periprosthetic infection; recurrent or irreducible dislocation

Conservative therapy not indicated

Recurrent disabling pain associated with clinically significant leg length inequality or audible noise

Replacement/Revision — Optimization Requirements (urgent/time-sensitive exceptions)

All patients who meet the above criteria for standard elective revision must also meet ALL of the following unless the replacement is urgent/time-sensitive (in which case i–iii can be waived):

BMI < 35 with same optimization documentation requirements if >35 (BMI >35 is relative contraindication; case-by-case review possible)BMI preferably < 35; >35 requires optimization over 3–6 months

No diabetes, or diabetes with HbA1c managed as above (A1c >7.5 requires active management and reduction over 3–6 months; A1c >8.0 relative contraindication)HbA1c < 7.5 preferred; A1c >7.5 requires active management

Nicotine/tobacco cessation requirements as listed above (30 days tobacco-free or 90% reduction)Nicotine/tobacco-free 30 days or 90% reduction

Other Considered Indications

Hip arthroplasty may be considered medically necessary for ANY of the following:

Conversion of previous hip surgeries due to progression of disease or failure (includes prior closed/open reduction and internal fixation, hemiarthroplasty, intramedullary nail, hip resurfacing, hip fusion, resection arthroplasty/Girdlestone)

Acute hip fracture confirmed by imaging

When conservative therapy is not indicated

Contraindications / Not Appropriate Situations

Total hip arthroplasty is considered not appropriate when ANY of the following are present:

Active infection of the hip joint or active systemic bacteremia

Active skin infection (except for recurrent cutaneous staph infections) or open infection within the planned surgical site of the hip

Unstable angina

Underlying medical/social issues such as dementia that interferes with successful rehabilitation; lack of caregiver/unstable home situation for rehabilitation; non-ambulatory patients

Verify authorization requirements and use the Pre-authorization Code Check. For Medicare members, inpatient requests for the listed inpatient-only codes are not subject to medical necessity review but must follow inpatient vs outpatient level-of-care guidance.

CPT codes: 27132, 27134, 27137, 27138, 27236, 27130
Use Pre-authorization Code Check to confirm plan-specific authorization requirements
Medicare inpatient-only codes (27132, 27134, 27137, 27138, 27236) are not subject to medical necessity review for Medicare members but follow level-of-care guidance

Denial Risk

Denial risk for missing conservative management documentation

Claims may be denied or not approved if documentation does not demonstrate required trials of conservative management or up-to-date imaging and if optimization efforts are not documented when applicable.

Documentation of medication trial (per policy; effective 01/01/2026 requires continuous anti-inflammatory use for minimum 6 weeks including BOTH acetaminophen and an NSAID unless contraindicated)
Trial of supervised physical therapy within the last 12 months (attendance >75% of sessions, minimum of 3 visits)
Documentation of intra-articular corticosteroid injections if appropriate
Imaging within the prior 12 months showing qualifying radiographic findings
Documentation of optimization efforts for BMI, HbA1c, and nicotine/tobacco cessation when applicable

Billing Rule

Inpatient vs Ambulatory status adjustments

If a patient is approved for ambulatory status but stays longer than expected, the inpatient claim could be adjusted to inpatient if deemed appropriate. For Medicare members, codes on the inpatient-only list should not be reviewed for ambulatory/outpatient status; follow inpatient vs outpatient level-of-care guidance.

Ambulatory approval does not preclude inpatient adjustment if length of stay extends and inpatient criteria are met
Medicare inpatient-only list codes should not be reviewed for ambulatory/outpatient status for Medicare members
If an orthopedist requests inpatient status despite not meeting standard inpatient criteria, submit a separate explanation for case-by-case clinical review

clarification_level_of_care

Clarified Level of Care Requirement for Medicare and Non-Medicare Members.

2023-02-06coding_clarification

Added clarification noting the Medicare inpatient-only (IPO) list update effective 01/01/2022.