CurrentPremera BluecrossPolicy 7.01.573

Hip Arthroplasty in Adults

Defines medical necessity criteria, documentation requirements, and coding for total hip arthroplasty and revision/replacement procedures for individuals aged 19 and older. Requires pre-approval by the health plan and specifies indications, contraindications, and required conservative management and imaging findings.

Policy Summary

PayerPremera Bluecross

PolicyHip Arthroplasty in Adults

Policy CodePolicy 7.01.573

Change TypeAnnual Review (references updated)

Effective DateApr 1, 2026

Next Review Date

Key ActionHip arthroplasty must be pre-approved by the health plan; submit documentation demonstrating that medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

Annual Review approved March 10, 2026; policy reviewed and references updated; policy statements unchanged.

19+Applies to adults aged

>=2Radiographic features required

3 monthsFailed conservative management duration

12 monthsValid imaging timeframe

Coverage Summary

This policy defines medical necessity criteria, documentation requirements, and coding for total hip arthroplasty and for revision/replacement procedures in adults aged 19 and older. It requires pre-approval by the health plan and specifies required indications, contraindications, radiographic thresholds, and conservative management prior to primary arthroplasty.

Total hip arthroplasty replaces diseased hip joint components with prosthetic implants to reduce pain and restore function; common indications include osteoarthritis, degenerative joint disease, rheumatoid arthritis, traumatic arthritis, avascular necrosis, and malignancy when appropriate.

Thresholds and Key Stat Items

Duration of disabling pain or failed conservative management>= 3 months

Imaging timeframeImaging within 12 months prior to planned surgery

Conservative physical therapy/exercise trial>= 12 weeks (physical therapy or flexibility/muscle strengthening)

Radiographic findings requiredAt least 2 of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, bone-on-bone articulation

Applies to adults aged19+

Radiographic features required (stats)>= 2

Failed conservative management duration (stats)3 months

Valid imaging timeframe (stats)12 months

Medical-Necessity Criteria

Total hip arthroplasty - Initial primary arthroplasty (Medical Necessity)

Total hip arthroplasty may be considered medically necessary for joint disease when ALL of the following criteria are met:

ALL of the following

ALL of the following
- Degenerative joint disease (DJD)
- Osteoarthritis (OA)
- Rheumatoid arthritis (RA)
- Traumatic arthritis
- Avascular necrosis
ANY of the following
- Disabling pain for at least 3 months duration>= 3 months
- Functional disability which interferes with the ability to carry out activities of daily living
At least 2 of the following
- Subchondral cysts
- Subchondral sclerosis
- Periarticular osteophytes
- Joint subluxation
- Severe joint space narrowing
- Bone on bone articulation
  Failure of a trial of physical measures is not required if radiographic or imaging findings show evidence of bone-on-bone articulation.
ANY of the following
- Non-steroidal anti-inflammatory drugs (oral or topical)
- Acetaminophen
- Intra-articular injection of corticosteroids as appropriate
- Physical therapy for ≥12 weeks>= 12 weeks
- Flexibility and muscle strengthening exercises for ≥12 weeks>= 12 weeks
- Reasonable restriction of activities for at least 12 weeks

Coding

Primary and Revision Hip Arthroplasty CPT Codes (covered 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; acetabular component only, with or without autograft or allograft
27138	Revision of total hip arthroplasty; femoral component only, with or without allograft

FDA product codes for hip implant devices (informational)mixed

MEH	FDA product code (hip implant device)
JDI	FDA product code (hip implant device)
JDG	FDA product code (hip implant device)
LWJ	FDA product code (hip implant device)
LPH	FDA product code (hip implant device)
LZO	FDA product code (hip implant device)
KWY	FDA product code (hip implant device)
KWA	FDA product code (hip implant device)

Provider Actions / Prior Authorization

Prior Authorization

Pre-approval required

Hip arthroplasty must be pre-approved by the health plan. Submit documentation demonstrating that the medical necessity criteria are met.

Documentation Required

Required clinical and imaging documentation

Medical records must document the following clinical and imaging information to support medical necessity for total hip arthroplasty:

Documented diagnosis (e.g., degenerative joint disease, osteoarthritis, rheumatoid arthritis, traumatic arthritis, or avascular necrosis).
Duration of disabling pain and/or functional limitation (at least 3 months) interfering with activities of daily living.
Imaging within 12 months prior to planned surgery demonstrating Tönnis grade 3 severe osteoarthritis or at least two of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, or bone-on-bone articulation.
Documentation of three months of failed non-operative conservative management (trial of medications and/or measures such as NSAIDs, acetaminophen, intra-articular corticosteroid injection as appropriate, ≥12 weeks of physical therapy or ≥12 weeks of flexibility and strengthening exercises, or reasonable activity restriction).

Documentation Required

Replacement/revision supporting evidence

For revision or replacement procedures, provide imaging or clinical documentation supporting one or more of the listed failure modes or complications.

Aseptic loosening of one or more prosthetic components confirmed by imaging
Bearing surface wear leading to symptomatic synovitis or local bone/soft tissue reaction
Component instability
Displaced periprosthetic fracture
Fracture, mechanical failure, or recall of a prosthetic component
Periprosthetic infection
Progressive or substantial periprosthetic bone loss
Recurrent or irreducible dislocation
Recurrent, disabling pain associated with clinically significant leg length inequality or audible noise

Background & Evidence

Total hip arthroplasty involves removing damaged bone and cartilage and replacing the femoral head/neck and acetabulum with prosthetic components made of combinations of metal, ceramic, or polyethylene; components may be cemented or press-fit (uncemented) and are selected based on patient anatomy and bone quality.

Implant materials and fixation methods have differing longevity and complication profiles: polyethylene wear can cause osteolysis and loosening, ceramic components may be brittle and can fracture or produce squeaking, metal-on-metal bearings have been associated with adverse local tissue reactions and higher revision rates, and cemented versus uncemented fixation have trade-offs related to longevity and patient age.

Registry data indicate most hip replacements last approximately 20 to 25 years and device-specific risks (including metal implant surveillance and FDA product codes) should be considered when selecting implants.

Definitions

Evidence / Guidelines

Name	Number	Effective / Status
Total Hip Arthroplasty (L36573)	L36573	2019-12-01 (now retired)

Revision History

2026-03-10annual_reviewLatest

Annual Review approved March 10, 2026; policy reviewed and references updated; policy statements unchanged.

2025-08-25annual_review

Annual Review approved August 25, 2025; policy reviewed. Policy statements unchanged.

2024-10-07annual_review

Annual Review approved October 7, 2024; policy reviewed; references updated. Policy statements unchanged.

2023-03-20annual_review

Annual Review approved March 20, 2023; policy reviewed. Added types of joint disease to be reviewed. Policy statements unchanged.

2021-03-02annual_review

Annual Review approved March 2, 2021; policy reviewed. References updated. Policy statements unchanged.

2020-03-10interim_action

Delete policy approved March 10, 2020; policy slated for deletion effective July 2, 2020 and replacement with InterQual criteria.

2020-02-20interim_review

Interim Review approved February 20, 2020. Added note that non-surgical medical management is not required if imaging shows bone-on-bone articulation.

2019-08-13new_policy

New policy approved August 13, 2019, effective January 1, 2020. Hip arthroplasty may be considered medically necessary when criteria are met.