CurrentPremera BluecrossPolicy 7.01.573

Hip Arthroplasty in Adults

Defines medical necessity criteria, documentation requirements, coding, and exclusions for total hip arthroplasty and revision/replacement procedures for individuals aged 19 and older. Requires pre-approval by the health plan.

Policy Summary

PayerPremera Bluecross

Policy7.01.573 Hip Arthroplasty in Adults

Policy CodePolicy 7.01.573

Change TypeAnnual Review (no change)

Effective DateApr 1, 2026

Next Review Date

Key ActionHip arthroplasty must be pre-approved by the health plan prior to the procedure; submit documentation demonstrating criteria are met.

SourceLink

POLICY UPDATE CHANGES

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

5Primary diagnosis categories listed for primary THA

9Revision/replacement indications listed

5Covered CPT codes listed

12 weeksPT/exercise trial requirement

Coverage Summary

Subject: Total Hip Arthroplasty (Hip Replacement) in Adults. Policy Number: 7.01.573. Status: CURRENT. Effective Date: 2026-04-01. Last Review: 2026-03-23. Scope summary: Defines medical necessity criteria, documentation requirements, coding, and exclusions for total hip arthroplasty and revision/replacement procedures for individuals aged 19 and older, and requires pre-approval by the health plan.

High-level coverage stance: Covered with criteria. Total hip arthroplasty is covered when the policy’s documented medical necessity criteria are met (including documented qualifying diagnoses, ≥ 3 months of disabling pain or functional disability, required imaging within 12 months showing severe osteoarthritis or bone-on-bone, and documentation of failed non-operative conservative management including medications and applicable physical measures).

Primary Total Hip Arthroplasty — Medical Necessity

Total hip arthroplasty - Medical Necessity (primary)

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

ALL of the following

ONE OF
- 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
ALL of the following
- Subchondral cysts
- Subchondral sclerosis
- Periarticular osteophytes
- Joint subluxation
- Severe joint space narrowing
- Bone on bone articulation
  If imaging shows bone-on-bone articulation, failure of a trial of physical measures is not required.
ANY of the following
- Non-steroidal anti-inflammatory drugs (oral or topical)
- Acetaminophen

Total hip arthroplasty - Additional medically necessary indications (primary)

Hip arthroplasty may be considered medically necessary when imaging findings show bone-on-bone articulation or for the following diagnoses:

ANY of the following

Acute hip fracture by imaging
Avascular necrosis, femoral head with unresponsive severe pain
Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur

Replacement / Revision — Medical Necessity

Replacement/revision of previous hip arthroplasty - Medical Necessity

Hip arthroplasty replacement/revision may be considered medically necessary when ONE or more of the following are present:

ANY of the following

Aseptic loosening of one or more prosthetic components confirmed by imaging
Bearing surface wear leading to symptomatic synovitis or local bone or 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

Not Medically Necessary / Exclusions

Not medically necessary / Exclusions

Total hip arthroplasty is considered not medically necessary when ANY of the following are present or when above indications are not met:

ANY of the following

Active infection of the hip joint or active systemic bacteremia
Active skin infection (except for recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip
Permanent or irreversible muscle weakness in the absence of pain that prevents ambulation
Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture
Neuropathic (Charcot) joint

Coding

Covered CPT codes for hip arthroplasty and revisionsCPTCovered

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

Device product codes (FDA devices referenced)mixed

MEH	FDA product code referenced for hip devices
JDI	FDA product code referenced for hip devices
JDG	FDA product code referenced for hip devices
LWJ	FDA product code referenced for hip devices
LPH	FDA product code referenced for hip devices
LZO	FDA product code referenced for hip devices
KWY	FDA product code referenced for hip devices
KWA	FDA product code referenced for hip devices

Provider Actions & Requirements

Prior Authorization

Pre-approval required

Hip arthroplasty must be pre-approved by the health plan prior to the procedure; submit documentation demonstrating criteria are met.

Pre-approval required prior to procedure

Documentation Required

Required clinical documentation

Medical records must document diagnosis, duration of disabling pain (≥3 months), imaging evidence (Tönnis grade 3 or bone-on-bone) within 12 months, and failed non-operative conservative management including medications and ≥12 weeks of physical measures as applicable.

Diagnosis
Duration of disabling pain ≥3 months
Imaging evidence (Tönnis grade 3 or bone-on-bone) within 12 months
Documentation of failed non-operative conservative management including medications and ≥12 weeks of physical measures
Documentation of any applicable intra-articular injections

Denial Risk

Denial if criteria not met

Claims may be denied if required medical necessity criteria, imaging, or documentation of conservative therapy trials are not provided.

Missing imaging performed within 12 months (including evidence of Tönnis grade 3 or bone-on-bone)
Missing documentation of trials of conservative therapy (≥3 months of disabling pain and ≥12 weeks of physical measures where required)
Missing pre-approval from the health plan

Background and Clinical Context

Background: Total hip arthroplasty (THA) is a common orthopedic procedure that removes diseased bone and cartilage of the hip and replaces it with prosthetic implants to reduce pain and restore function. It is most often performed for severe osteoarthritis (degenerative arthritis) that persists despite conservative treatment; other indications include rheumatoid arthritis, posttraumatic arthritis, avascular necrosis, acute hip fracture, and malignancy involving the joint.

Implant components and fixation: Prosthetic components include a femoral component (stem and head), an acetabular component (shell and liner), and a bearing surface. Materials vary (metal, ceramic, plastic/highly crosslinked polyethylene) and components may be cemented or press-fit (uncemented) to bone. Component choices affect wear, longevity, and complication risk (for example, polyethylene wear can cause osteolysis; ceramic may be brittle; metal-on-metal has been associated with adverse local tissue reactions and is no longer marketed for total hip replacements in the U.S.).

Complications: Potential procedure-specific complications include aseptic loosening, dislocation, intraoperative and periprosthetic fractures, leg length discrepancy, osteolysis and wear-related bone loss, thromboembolism, and device-specific issues such as metal-related local tissue reactions or systemic metal ion concerns.

Guideline and regulatory context: National and specialty guidelines (AAOS, NICE, OARSI, others) support trial of non-surgical management prior to surgery and inform conservative care recommendations. Devices and instruments used in THA require FDA regulation; product codes referenced include MEH, JDI, JDG, LWJ, LPH, LZO, KWY, and KWA, and FDA actions have impacted the use of metal-on-metal implants.

Evidence highlights

Typical implant longevityApproximately 20 to 25 years

Tönnis grade meaningGrade 3 indicates severe OA (large cysts, severe joint space narrowing/obliteration)

Term	Definition
Tönnis grade 3
Radiographic evidence of large cysts in the femoral head or acetabulum, severe joint space narrowing or obliteration of the joint space, and severe deformity and loss of sphericity of the femoral head.

Policy Summary

PayerPremera Bluecross

Policy7.01.573 Hip Arthroplasty in Adults

Policy CodePolicy 7.01.573

Change TypeAnnual Review (no change)

Effective DateApr 1, 2026

Next Review Date

Key ActionHip arthroplasty must be pre-approved by the health plan prior to the procedure; submit documentation demonstrating criteria are met.

SourceLink

On This Page

OpenPayer

Hip Arthroplasty in Adults

Coverage Summary

Primary Total Hip Arthroplasty — Medical Necessity

Replacement / Revision — Medical Necessity

Not Medically Necessary / Exclusions

Coding

Provider Actions & Requirements

Background and Clinical Context

Definitions

Revision History