CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Knee Arthroplasty

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This guideline describes the clinical criteria and documentation MassHealth uses to determine medical necessity for total, unicompartmental/partial, and revision knee arthroplasty. It applies to providers requesting prior authorization for MassHealth members; approval remains subject to eligibility, other insurance, and program requirements.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Knee Arthroplasty

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization requests for knee arthroplasty through a MassHealth orthopedic surgeon with the required procedure, diagnosis, and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Knee arthroplasty procedure types addressed

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Knee Arthroplasty

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Knee Arthroplasty

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization requests for knee arthroplasty through a MassHealth orthopedic surgeon with the required procedure, diagnosis, and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Knee arthroplasty procedure types addressed

3+ monthsMinimum non-operative treatment for total knee arthroplasty

6+ monthsMinimum symptom and treatment period for partial knee arthroplasty

KL III-IVRequired radiographic degeneration

BMI >40Relative contraindication and enhanced documentation trigger

24 weeksEnhanced treatment period for certain partial arthroplasty requests

Medical Necessity Criteria

Total Knee Arthroplasty

TKA may be medically necessary when all criteria a through e are met.

Total knee arthroplasty

Disease or damage: Extensive disease or damage due to rheumatoid arthritis, fracture, or avascular necrosis confirmed by radiographs, MRI, or other advanced imaging.
Symptoms and failed treatment: Both persistent severe pain or documented loss of function for at least 6 months resulting in a diminished quality of life, and at least 3 months of non-operative care including at least 2 Appendix A treatments that failed to improve those symptoms.Symptoms or functional loss: at least 6 months; non-operative care: at least 3 months; at least 2 treatments
Physical examination
- Degenerative examination findings: Tenderness, swelling, effusion, and limited range of motion compared with the uninvolved side or a normal joint.
- Alternative examination findings: Flexion contracture, palpable or audible crepitus, instability, or angular deformity.
Imaging: MRI and weight-bearing radiographs show bicompartmental or tricompartmental advanced arthritic changes at Kellgren-Lawrence stage III or IV degeneration.Kellgren-Lawrence stage III or IV
See Appendix B grading system.
Bilateral replacement review: A request for simultaneous bilateral total knee replacements in a member with chronic, painless effusion and extensive radiographic arthritis is reviewed case by case.
This is a case-by-case review provision rather than an automatic coverage criterion.

Unicompartmental/Partial Knee Arthroplasty

UKA/PKA may be medically necessary as an alternative to TKA for documented unicompartmental disease when all criteria a through g are met.

Unicompartmental/partial knee arthroplasty

Localized pain: Pain has been present for at least 6 months and is localized to the medial or lateral compartment.At least 6 months
Failed non-operative care: At least 6 months of non-operative care, including at least 2 Appendix A treatments, has failed to improve symptoms.At least 6 months; at least 2 treatments
Motion and alignment: Goniometer examination shows a total arc of motion greater than 90 degrees, contracture less than 5-10 degrees, and angular deformity less than 10 degrees that is passively correctable to neutral.

Revision Arthroplasty

Revision arthroplasty/TKA may be medically necessary when either criterion a or criterion b is present.

Revision arthroplasty

Previous arthroplasty with infection excluded: The member has had a previous UKA/PKA or TKA, infection has been ruled out by synovial fluid aspiration or biopsy with cell count and/or culture, and the member is off antibiotics.
Symptomatic failed implant
- Symptoms: The member has symptomatic UKA/PKA or TKA, evidenced by persistent, severe disabling pain and loss of function.
- Physical examination abnormality: At least one of the following is present: tenderness to palpation objectively attributable to the implant, swelling, effusion, pain on weight-bearing or motion, instability on stress-testing, abnormal or limited motion compared with usual function, or palpable or audible crepitus associated with reproducible pain.

The following techniques and procedures are considered investigational or experimental and are not covered: computer-navigated, patient-specific, or gender-specific instrumentation; bicompartmental arthroplasty; and robot-assisted total knee arthroplasty (TKA), including Makoplasty.

Active infection—whether systemic, local to the knee, or remote from the knee—is an absolute contraindication to total knee replacement, unicompartmental/partial knee arthroplasty (UKA/PKA), and revision arthroplasty.

UKA/PKA is absolutely contraindicated when inflammatory arthritis significantly involves other knee compartments; angular deformity or contracture exceeds the specified range; ligamentous instability is present, including anterior cruciate ligament instability; bone quality is poor or there is significant osteoporosis or osteopenia; the opposite compartment has been meniscectomized; or knee stiffness exceeds the specified range of motion.

MassHealth does not consider knee arthroplasty medically necessary when the requested procedure is an investigational or experimental technique, including computer-navigated, patient-specific, or gender-specific instrumentation; bicompartmental arthroplasty; or robot-assisted TKA (Makoplasty).

TKA or revision arthroplasty may not be medically necessary when relative contraindications are present. These include prior infection without an adequate negative evaluation, BMI greater than 40, an articular injection within the previous 3 months, extensor mechanism deficiency, a neuropathic joint, unstable or poorly controlled comorbidities, severe peripheral vascular disease, or a compromised soft-tissue envelope. For a prior infection, the guideline specifies evaluation including aspiration with cultures and serology, complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein; intraoperative tissue biopsy may also be needed to exclude latent infection.

Clinical Thresholds and Coding Reference

TKA symptom duration

Required symptomPersistent severe pain or documented loss of function

DurationAt least 6 months

Functional impactSymptoms must result in a diminished quality of life

TKA non-operative treatment

Treatment durationThree months or more of non-operative care

Treatment countAt least two treatments from Appendix A

Treatment outcomeThe treatment must have failed to improve the qualifying pain or loss of function

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for knee arthroplasty. MassHealth reviews each request for medical necessity; approval remains subject to member eligibility, other insurance, and all applicable MassHealth program requirements.

Documentation Required

Orthopedic Surgeon Submission

The request must be submitted by an orthopedic surgeon who is a MassHealth provider and must identify the requested arthroplastic procedure and the request-specific information needed for review.

Submitting provider: orthopedic surgeon who is a MassHealth provider.
Identify the requested procedure and include the appropriate CPT code(s).
Submit all information pertinent to the diagnosis and requested service.

Clinical Context

Knee arthroplasty is an orthopedic surgical procedure used to address pain or decreased function caused by arthritic or traumatic knee damage. It replaces, reconstructs, remodels, or realigns damaged articular surfaces to relieve pain and improve stiffness or mobility. The guideline considers arthroplasty when non-operative treatment no longer adequately controls pain or functional loss and evaluates each request based on the relative risks and benefits, including postoperative recovery.

Arthroplasty Terms

Knee arthroplasty

Procedure typeAn orthopedic surgical procedure for a knee damaged by arthritis or trauma

Articular surfacesMay replace, remodel, or realign articular surfaces

Treatment goalImprove joint stiffness or mobility and relieve pain

Total knee arthroplasty (TKA)

ProcedureSurgical reconstruction or replacement of all articular joint surfaces

Anatomic scopeThe entire knee joint

Indications describedA malformed or degenerated knee joint, or failure or complications of previous knee arthroplasty

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Knee Arthroplasty

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2018

Next Review DateN/A

Key ActionSubmit prior authorization requests for knee arthroplasty through a MassHealth orthopedic surgeon with the required procedure, diagnosis, and supporting clinical documentation.

SourceLink

On This Page

Total arc >90 degrees; contracture <5-10 degrees; angular deformity <10 degrees

ACL stability: The ACL is normal or stably reconstructed on physical examination.

Age: Member is older than 50 years.Age >50 years

Members younger than 50 require documentation of at least 24 weeks of unsuccessful non-operative treatment, including an assistive device, therapeutic injections, and a weight reduction program.

Unicompartmental imaging: MRI and weight-bearing radiographs demonstrate only unicompartmental disease, with or without patellofemoral involvement, with Kellgren-Lawrence stage III or IV degeneration.Kellgren-Lawrence stage III or IV

See Appendix B grading system.

BMI is less than 40.BMI <40

Members with BMI greater than 40 require documentation of at least 24 weeks of unsuccessful non-operative treatment, including an assistive device, therapeutic injections, and a weight reduction program.

Imaging confirmation: Aseptic loosening or osteolysis is confirmed by radiographic or advanced imaging, including a nuclear medicine bone scan, CT scan, or MRI.

Radiographic degeneration

Imaging requiredMRI and weight-bearing radiographs

Disease distributionBicompartmental or tricompartmental advanced arthritic changes

Required severityKellgren-Lawrence stage III or stage IV degeneration

UKA/PKA symptom and treatment duration

Pain durationAt least 6 months

Pain locationLocalized to the medial or lateral compartment

Failed careAt least 6 months of non-operative care, including at least two Appendix A treatments, must have failed to improve symptoms

UKA/PKA joint motion and alignment

Total arc of motionGreater than 90 degrees

ContractureLess than 5-10 degrees

Angular deformityLess than 10 degrees

Passive correctionAngular deformity must be passively correctable to neutral

UKA/PKA age and BMI

AgeOlder than 50 years

BMILess than 40

ExceptionsMembers younger than 50 years or with BMI greater than 40 require documentation of at least 24 weeks of unsuccessful non-operative treatment

Enhanced non-operative treatment

Required durationAt least 24 weeks of unsuccessful non-operative treatment

Assistive deviceTreatment must include use of an assistive device

Therapeutic injectionsTreatment must include therapeutic injections

Weight reductionTreatment must include a weight reduction program

Denial Risk

Failed Conservative Treatment

Document the applicable completed and failed non-operative treatment before requesting primary knee arthroplasty. Treatment options may include activity modification or rest, bracing or walking aids, protected weight bearing, weight optimization, physical therapy or supervised home exercise, ice or heat, and oral or topical NSAIDs, other analgesics, or injections such as cortisone.

TKA: at least 3 months of non-operative care, including at least two Appendix A treatment categories, must have failed to improve the qualifying persistent severe pain or functional-loss symptoms.
UKA/PKA: at least 6 months of non-operative care, including at least two Appendix A treatment categories, must have failed to improve symptoms.
Summarize the treatments attempted, their duration, and the unsuccessful response.

Denial Risk

Enhanced UKA/PKA Treatment Requirement

For UKA/PKA members younger than 50 years or with BMI greater than 40, documentation must confirm at least 24 weeks of unsuccessful non-operative treatment before the procedure is considered.

The 24-week treatment must include an assistive device, therapeutic injections, and a weight reduction program.
Document completion and unsuccessful results for each required component.

Documentation Required

Required Clinical Documentation

Submit complete clinical documentation supporting medical necessity and the specific arthroplasty requested.

Primary diagnosis name(s) and ICD-CM code(s), plus pertinent secondary diagnoses, comorbidities, and their ICD-CM code(s).
Specific arthroplastic procedure and appropriate CPT code(s).
Most recent medical evaluation, medical history, physical examination, orthopedic knee examination, and condition-specific testing.
Relevant radiology and other test results, including routine radiographs, MRI, or CT when performed.
Summary of unsuccessful conservative treatment, risk factors, comorbid conditions, and any other pertinent information MassHealth requests.

Billing Rule

Submitting Provider and Channel

The orthopedic surgeon should submit the complete request electronically when possible through the Provider Online Service Center (POSC). Alternatively, submit the MassHealth Prior Authorization Request PA-1 form with pertinent documentation to the address on the form; POSC questions may be directed to the MassHealth Customer Service Center at 1-800-841-2900.

The submitting provider must be an orthopedic surgeon enrolled as a MassHealth provider.
Use POSC or the PA-1 paper form and attach all pertinent clinical documentation.
Include the diagnosis, requested procedure, codes, and all information relevant to medical necessity.

Documentation Required

Procedure-Specific Clinical Support

Match the clinical record to the requested procedure and document the findings required for that arthroplasty type.

TKA: document rheumatoid arthritis, fracture, or avascular necrosis confirmed by imaging; persistent severe pain or documented functional loss for at least 6 months with diminished quality of life; qualifying examination findings; and MRI or weight-bearing radiographs showing bicompartmental or tricompartmental Kellgren-Lawrence stage III or IV degeneration. Simultaneous bilateral TKA requests are reviewed case by case.
UKA/PKA: document at least 6 months of localized medial or lateral compartment pain; physical examination showing total arc of motion greater than 90 degrees, contracture less than 5–10 degrees, and passively correctable angular deformity less than 10 degrees; a normal or stably reconstructed ACL; age over 50 unless the enhanced 24-week requirement applies; and imaging showing only unicompartmental Kellgren-Lawrence stage III or IV disease, with or without patellofemoral involvement. BMI must be less than 40 unless the enhanced requirement applies.
Revision arthroplasty/TKA: document prior UKA/PKA or TKA with infection ruled out by synovial aspiration or biopsy and the member off antibiotics, or document symptomatic disabling pain and loss of function, qualifying examination findings, and aseptic loosening or osteolysis confirmed by radiographic or advanced imaging.

Denial Risk

Excluded Experimental Procedures

Do not request the following procedures as covered knee arthroplasty services; MassHealth considers them investigational or experimental and does not cover them.

Computer-navigated, patient-specific, or gender-specific instrumentation.
Bicompartmental arthroplasty.
Robot-assisted TKA (Makoplasty).

Denial Risk

Absolute Contraindication: Active Infection

Active infection is an absolute contraindication to TKA, UKA/PKA, and revision arthroplasty, whether the infection is systemic, local to the knee, or remote to the knee.

Do not proceed with or request arthroplasty when active systemic, local, or remote infection is present.

Denial Risk

Contraindications and Clinical Risk Factors

Screen for relative contraindications and document evaluation, mitigation, and any specialist input before submission. UKA/PKA also has procedure-specific absolute contraindications that must be excluded.

Relative contraindications to TKA: prior infection at the site unless aspiration with cultures and serology, CBC with differential, ESR, and CRP demonstrate no infection; obtain intra-operative tissue biopsies when indicated to exclude latent or dormant infection; BMI greater than 40; or articular injection within the last 3 months.
Relative contraindications to TKA or revision arthroplasty/revision TKA: extensor-mechanism deficiency, neuropathic joint, unstable or poorly controlled comorbidities, severe peripheral vascular disease, or a compromised soft-tissue envelope. Revision may require plastic-surgical consultation for soft-tissue coverage.
Absolute contraindications to UKA/PKA: inflammatory arthritis or significant arthritis in other compartments, angular deformity or contracture beyond the permitted range, ligamentous instability including ACL deficiency, poor bone quality or significant osteoporosis or osteopenia, meniscectomy of the opposite compartment, or stiffness beyond the permitted range of motion.

Denial Risk

Failure to Meet Clinical Criteria

Requests are at risk of denial when the record does not establish the procedure-specific symptoms, duration and failure of conservative treatment, imaging, physical findings, or other required clinical criteria.

Verify that the requested arthroplasty type is supported by the applicable diagnosis, imaging, examination, symptom duration, and treatment history.
For UKA/PKA, verify compartment-limited disease, ACL stability, permitted range of motion and deformity, and the applicable age and BMI requirements.
For TKA, verify advanced bicompartmental or tricompartmental disease and the required persistent symptoms, functional impact, examination findings, and failed treatment.
For revision procedures, verify prior arthroplasty, infection exclusion, symptoms and examination findings, and imaging evidence of aseptic loosening or osteolysis.

Unicompartmental/partial knee arthroplasty (UKA/PKA)

Reconstructed compartmentsThe medial or lateral weight-bearing compartment and/or the patellofemoral joint

Alternative toMay be considered as an alternative to total knee arthroplasty for documented unicompartmental disease

Alternate terminologyAlso called partial, hemi-, or unicondylar knee arthroplasty

Revision arthroplasty

ProcedureSurgical reconstruction of the knee

ReasonFailure or complication of a previous arthroplasty

Prior proceduresPrevious UKA/PKA or TKA

Kellgren-Lawrence grades III-IV

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

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

Clinical useStages III and IV describe the advanced radiographic degeneration specified in the knee arthroplasty criteria