Premera Bluecross Hip Arthroplasty Prior Auth Update

Initial total hip arthroplasty

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

Main inclusion: There is a documented diagnosis of one of the following: degenerative joint disease (DJD), osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, or avascular necrosis.

Apply only to individuals aged 19 and older.

Symptom severity: Treatment is needed because of one or more of the following: disabling pain for at least 3 months duration, or functional disability which interferes with activities of daily living.>= 3 months

Imaging evidence: Radiographic or imaging evidence of severe osteoarthritis (Tönnis grade 3) in the 12 months prior to surgery as evidenced by two or more of the following: subchondral cysts; subchondral sclerosis; periarticular osteophytes; joint subluxation; severe joint space narrowing; bone-on-bone articulation.Imaging within 12 months prior to planned surgery

Failure of a trial of physical measures is not required if imaging shows bone-on-bone articulation.

Conservative management: Documentation of three months of failed non-operative conservative management, demonstrated by trial of one or more of the following medications: non-steroidal anti-inflammatory drugs (oral or topical) or acetaminophen, and as appropriate intra-articular corticosteroid injection; and trial of one or more of the following physical measures: physical therapy for ≥12 weeks, or flexibility and muscle strengthening exercises for ≥12 weeks, or reasonable restriction of activities for at least 12 weeks.>= 3 months

Not required if bone-on-bone imaging per above.

Revision/replacement indications

Hip arthroplasty for replacement/revision of previous arthroplasty may be considered medically necessary when ANY of the following are present:

Revision indications: 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.

Documentation must support at least one listed indication.

General medical necessity statement

Policy statements referenced indicate hip arthroplasty may be considered medically necessary when established criteria are met; conservative therapy is recommended unless specific imaging findings apply.

General: Total hip arthroplasty is considered medically necessary when the policy criteria are met. Conservative non-surgical management (education, exercise, weight reduction, physical therapy, use of assistive devices, and intra-articular corticosteroid injection as appropriate) is recommended prior to surgery unless radiographic evidence such as bone-on-bone articulation obviates the requirement for a trial of physical measures.

See specific criteria for age applicability (applies to individuals aged 19 and older) and documentation requirements (imaging within 12 months, demonstration of failed conservative care unless bone-on-bone).

The policy lists specific exclusionary conditions that, if present, render total hip arthroplasty contraindicated. These include: active infection of the hip joint or active systemic bacteremia; active skin infection or open wound within the planned surgical site (except recurrent cutaneous Staphylococcus infections); permanent or irreversible muscle weakness without pain that prevents ambulation; rapidly progressive neurologic disease (except when there is a concomitant displaced femoral neck fracture); and a neuropathic (Charcot) joint.

The policy notes FDA regulatory actions relevant to metal-on-metal (MoM) total hip replacement devices. A 2016 FDA final order required premarket approvals for all MoM total hip implants and manufacturers were instructed to stop marketing those devices pending approval; as a result, no FDA‑approved MoM total hip replacement devices are currently marketed in the U.S. This regulatory status affects coverage because MoM total hip replacement devices are not marketed for use absent FDA approval.

Total hip arthroplasty is considered not medically necessary when the required indications and documentation are not met or when any of the listed exclusionary conditions are present (for example, the exclusions cited above such as active joint infection or systemic bacteremia).

The policy clarifies the regulatory interpretation for non–FDA‑approved MoM devices: because the FDA required premarket approvals and manufacturers were required to stop marketing MoM total hip implants pending approval, the use of non–FDA‑approved MoM total hip replacement devices is unsupported by current FDA marketing status and therefore is not considered an FDA‑marketed implant for purposes of this policy.

Coding and Billing

Covered CPT CodesCPTCovered

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 mentionedmixed

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

Duration of non-operative management required prior to THA

Required duration>= 3 months of disabling pain or failed non-operative management

Conservative therapies includedNSAIDs (oral/topical), acetaminophen, and intra‑articular corticosteroid when appropriate

Physical measuresPhysical therapy ≥12 weeks, or flexibility/strengthening exercises ≥12 weeks, or activity restriction ≥12 weeks

ExceptionFailure of conservative measures not required if imaging shows bone‑on‑bone articulation

Imaging recency requirement for planned surgery

Imaging timeframeRadiographs or other imaging must be performed within 12 months prior to planned surgery

Required imaging findings for initial THAEvidence of severe OA (Tönnis grade 3) demonstrated by two or more findings (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, or bone‑on‑bone)

Documentation useImaging within 12 months is required to support medical necessity and may obviate conservative trial if bone‑on‑bone

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Hip arthroplasty must be pre-approved by the health plan. Prior authorization is required before scheduling total hip arthroplasty to allow review of medical necessity and documentation.

Affected CPT codes for THA should be submitted for review (see coding guidance in provider portal).
Prior authorization verifies criteria such as diagnosis, duration of disabling pain, imaging evidence, and conservative therapy trials.

Documentation Required

Conservative Therapy Requirement

A trial of non-operative conservative management is required for most elective total hip arthroplasty cases. Documentation should show a failed trial of approximately three months of conservative therapy prior to approval unless radiographic bone-on-bone articulation is present.

Three months of failed non-operative conservative management is required for OA/DJD/RA/traumatic arthritis/avascular necrosis unless bone-on-bone is documented.
If imaging shows bone-on-bone articulation, the trial of physical measures is not required.

Note

Conservative Management Recommended

Conservative management is recommended prior to surgery and includes education, exercise, weight reduction, physical therapy, assistive devices, and intra-articular corticosteroid injections as appropriate.

Education about lifestyle changes, exercise, pacing activities, and weight reduction.
Referral to physical therapy for evaluation and exercise instruction; PT for ≥12 weeks or equivalent home exercise/flexibility and strengthening for ≥12 weeks.
Use of assistive devices such as canes or walkers when appropriate.
Intra-articular corticosteroid injections may be used for moderate to severe pain not responding to oral agents.

Documentation Required

Required Documentation for Medical Necessity

The individual's medical records submitted for review must document that medical necessity criteria are met. Provide specific elements in the record to support approval.

Diagnosis: Clear documentation of OA, DJD, RA, traumatic arthritis, or avascular necrosis (or other listed indications).
Symptoms: Duration and severity — disabling pain for ≥3 months and/or functional limitation interfering with ADLs.
Imaging: Radiographs or imaging within 12 months prior to surgery showing two or more features of severe osteoarthritis (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, or bone-on-bone articulation).
Conservative treatments tried: Record of a ≥3-month trial of failed non-operative care (NSAIDs, acetaminophen, and/or intra-articular corticosteroid as appropriate) and physical measures (PT ≥12 weeks, or ≥12 weeks of strengthening/flexibility exercises or reasonable activity restriction).
For revisions: Documentation of indication such as aseptic loosening confirmed by imaging, bearing surface wear with symptomatic reaction, component instability, displaced periprosthetic fracture, mechanical failure/recall, periprosthetic infection, progressive bone loss, recurrent dislocation, or persistent disabling pain with leg length inequality/noise.

Denial Risk

Denial Triggers for THA

Procedures lacking the required indications or documentation are at risk for denial. Common denial triggers include missing diagnostic criteria, absent or outdated imaging, no documented trial of conservative therapy when required, and active contraindications.

No documentation of a qualifying diagnosis (OA/DJD/RA/traumatic arthritis/avascular necrosis) or other covered indications.
Imaging not performed within 12 months prior to planned surgery or imaging fails to show required features of severe OA.
No record of a three-month failed conservative management trial when indicated (unless bone-on-bone documented).
Active infection at the hip joint, active systemic bacteremia, active skin infection at the surgical site, or other listed contraindications (e.g., neuropathic Charcot joint).
Incomplete medical records that do not substantiate disabling pain duration or functional limitations.

Note

Policy History and Enforcement Note

This policy has a history of reviews and updates. Coverage is contingent on meeting the current stated criteria; failure to meet criteria may result in non-coverage or denial. Providers should ensure submissions align with the latest effective policy.

Policy effective date: 2026-04-01. Criteria must be met as written on the effective date.
Previous updates clarified that non-surgical management is not required if bone-on-bone is present.
Failure to meet current criteria may result in claim non-coverage or denial; prior authorizations are issued based on the policy in effect at the time of request.

Note

References / Supporting Evidence

Extensive clinical references are provided as supporting documentation for the rationale and recommendations in this policy. Providers may refer to these sources when preparing prior authorization requests and clinical records.

Selected references include AAOS guidance, UpToDate reviews, systematic reviews, and clinical studies (see References section).
Evidence cited supports conservative management recommendations and criteria for imaging and indications for arthroplasty.

OpenPayer

Hip Arthroplasty in Adults

Coverage Criteria for Total Hip Arthroplasty

Coding and Billing

Provider Actions, Prior Authorization, and Documentation

Background and Policy Scope

Definitions and Key Terms

Policy Revision History