CurrentPremera BluecrossPolicy N/A

Hip Arthroplasty in Adults (Total Hip Replacement)

Defines when total hip arthroplasty and revision hip arthroplasty for individuals aged 19 and older are considered medically necessary, the documentation required for review, and coding references for Premera Blue Cross.

Policy Summary

PayerPremera Bluecross

PolicyHip Arthroplasty in Adults (Total Hip Replacement)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateSep 1, 2025

Key ActionObtain prior authorization with documentation of diagnosis, ≥3 months of disabling symptoms or failed conservative therapy, and imaging within 12 months showing severe osteoarthritis when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19+Applies to age (years)

3 moMinimum conservative therapy

Tonnis 3Required radiographic severity

No NCDMedicare NCD

>40References cited

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Primary total hip arthroplasty

Covered when ALL of the following are met

Primary THA medical necessity: 1) Age 19 or older; 2) Documented diagnosis of one of: degenerative joint disease/osteoarthritis, rheumatoid arthritis, traumatic arthritis, or avascular necrosis; 3) Treatment needed because of disabling symptoms for at least 3 months interfering with activities of daily living (ADLs); 4) Radiographic or imaging evidence within 12 months of severe osteoarthritis (Tonnis grade 3) demonstrated by two or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, or bone-on-bone articulation (note: failure of conservative measures is not required if bone-on-bone); 5) Documentation of a three-month trial of failed non-operative conservative management including one or more of: NSAIDs (oral or topical), acetaminophen, intra-articular corticosteroid injection as appropriate, and one or more physical measures (physical therapy for 2–12 weeks, flexibility/strengthening exercises for 2–12 weeks, or activity restriction for at least 12 weeks).all conditions must be met

Failure of conservative therapy not required if imaging shows bone-on-bone articulation.

Replacement/revision arthroplasty

Covered when ANY of the following are present

Revision/replacement indications: Aseptic loosening of one or more prosthetic components confirmed by imaging; bearing surface wear causing 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; acute hip fracture demonstrated by imaging; avascular necrosis with unresponsive severe pain; malignancy involving joint bones or soft tissues; non-union or malunion of articular fracture.

Any one of these documented conditions can meet medical necessity for replacement or revision arthroplasty.

Contraindications / Not medically necessary

Not medically necessary when ANY of the following are present

Exclusion criteria: Active infection of the hip joint or active systemic bacteremia; active skin infection or open wound within the planned surgical site; permanent or irreversible muscle weakness that prevents ambulation; rapidly progressive neurological disease (except when associated with a concomitant displaced femoral neck fracture); neuropathic (Charcot) joint.

Presence of any listed condition renders total hip arthroplasty not medically necessary.

Clinical guidance referenced

Clinical context and guideline-based considerations cited in support of coverage decisions:

Conservative care emphasized: Guidelines (NICE, OARSI) recommend non-surgical management including education, exercise, weight reduction, physical therapy, and other measures to unload the joint prior to considering surgery unless specific exceptions apply (for example, bone-on-bone radiographic disease).

Non-surgical management may not be required if imaging demonstrates bone-on-bone articulation.

Use of intra-articular injections: Intra-articular corticosteroid injections may be considered for short-term symptom relief (approximately 2–10 weeks) when other pharmacologic treatments are ineffective or unsuitable; NICE does not recommend intra-articular hyaluronan for osteoarthritis.

Injections are temporizing and may be used prior to surgery per clinical guidance.

Device regulatory considerations: Document device type and bearing surface given FDA regulatory status; manufacturers were required to stop marketing metal-on-metal (MoM) total hip implants pending premarket approval and currently there are no FDA‑approved MoM total hip replacement devices marketed in the US (with limited exceptions for resurfacing devices).

The procedure is considered not medically necessary when the required indications are not met or when any of the following exclusion conditions are present. Exclusions include: active infection of the hip joint or active systemic bacteremia; active skin infection or an open wound within the planned surgical site; permanent or irreversible muscle weakness that prevents ambulation; rapidly progressive neurologic disease (except in the clinical situation of a concomitant displaced femoral neck fracture); and neuropathic (Charcot) joint.

Manufacturers were required by the FDA final order (2016) to stop marketing metal-on-metal (MoM) total hip implants pending premarket approval. As noted in the regulatory summary, to date there are no FDA‑approved metal-on‑metal total hip replacement devices marketed for use in the United States.

When the clinical indications listed in this policy are not met, or when any exclusion criterion is present, total hip arthroplasty (THA) is considered not medically necessary and will not be authorized.

Guidance from NICE emphasizes non-surgical management for osteoarthritis and advises against certain therapies. Specifically, NICE does not recommend intra-articular hyaluronan injections and does not recommend offering glucosamine or strong opioids for osteoarthritis management. The guidance also states that intra-articular corticosteroid injections may be considered for short-term relief (2–10 weeks) when other pharmacologic treatments are ineffective or unsuitable.

Billing and Coding References

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 referencedmixed

MEH	FDA product code for devices used during hip surgery (listed in policy)
JDI	FDA product code for devices used during hip surgery (listed in policy)
JDG	FDA product code for devices used during hip surgery (listed in policy)
LWJ	FDA product code for devices used during hip surgery (listed in policy)
LPH	FDA product code for devices used during hip surgery (listed in policy)
LZO	FDA product code for devices used during hip surgery (listed in policy)
KWY	FDA product code for devices used during hip surgery (listed in policy)
KWA	FDA product code for devices used during hip surgery (listed in policy)

Conservative therapy duration — key facts

Conservative therapy durationAt least 3 months of failed non-operative conservative management (medications and physical measures) is required before primary THA unless bone-on-bone articulation is documented.

Examples of conservative therapies to documentTrials may include NSAIDs (oral or topical), acetaminophen, and intra‑articular corticosteroid injection (as appropriate).

Physical therapy requirementEvidence of physical therapy, flexibility and strengthening exercises, or activity restriction (2–12 weeks for PT or exercises; activity restriction ≥12 weeks) as part of conservative care.

Radiographic timeframe and severity — key facts

Radiographic timeframeRadiographs or imaging must be performed within 12 months prior to the planned surgery.

Required radiographic severityImaging must show severe osteoarthritis (Tonnis grade 3) or at least two of the following severe findings: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, or bone-on-bone articulation.

Exception to conservative therapyFailure of conservative therapy is not required if imaging documents bone-on-bone articulation.

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization required — Total hip arthroplasty (THA) must be pre-approved by the health plan prior to surgery. Submit a complete prior authorization request following the member's plan processes and timelines. Requests lacking required documentation may be returned or denied.

Applies to adults aged 19 and older
Include anticipated procedure date and operative side

Documentation Required

Conservative Therapy Requirement

Conservative (non‑operative) therapy must be documented as failed for at least three months prior to THA unless an exception applies (see bone‑on‑bone exception below). Documentation should show specific therapies attempted and duration.

Medication trials (NSAIDs oral/topical, acetaminophen) and responses
Physical measures: physical therapy (≈2–12 weeks), flexibility/strengthening exercise program, activity modification (≥12 weeks)
Intra‑articular corticosteroid injection when appropriate

Note

Non‑surgical Management Emphasis

Non‑surgical management should be emphasized and documented prior to surgical consideration. Educate and document counseling on lifestyle measures, exercise, pacing of activities, weight reduction, and referral to physical therapy where appropriate.

Education on activity modification and weight loss
Prescription or referral for targeted exercise/physical therapy and use of assistive devices as appropriate
Use of conservative pharmacologic measures (NSAIDs, acetaminophen) and short‑term intra‑articular corticosteroid for symptom relief when indicated

Documentation Required

Required Documentation for Necessity Review

Required documentation for medical necessity review — medical records submitted must clearly demonstrate that policy criteria are met. Incomplete records are a common basis for denial.

Documented diagnosis (e.g., OA, DJD, RA, avascular necrosis) and indication for surgery
Duration: ≥3 months of disabling symptoms and functional limitation interfering with ADLs (unless bone‑on‑bone exception)
Imaging: radiographs or imaging within 12 months prior to planned surgery showing severe OA (≥2 radiographic features such as subchondral cysts, sclerosis, osteophytes, subluxation, severe joint space narrowing or bone‑on‑bone)
Details of conservative management tried (medications, PT, activity restriction, injections) with dates and outcomes
For revision/replacement: documentation of aseptic loosening, component instability, bearing surface wear, periprosthetic fracture, infection, substantial bone loss, recurrent dislocation, or other specific surgical indications
Operative report and device information (planned device type and bearing surface)

Denial Risk

Denial Triggers for THA

Denial triggers — conditions or missing elements that commonly result in a determination of not medically necessary.

Absence of documented trial of conservative management when required (no dates, duration, or specifics)
No imaging within 12 months or imaging not demonstrating severe OA when required
Indication not supported by clinical or radiographic findings (e.g., neuropathic/Charcot joint, active hip or systemic infection, active skin infection at surgical site)
Permanent or irreversible muscle weakness that prevents ambulation without likelihood of improvement
Rapidly progressive neurological disease (except with displaced femoral neck fracture)
Missing or insufficient documentation of functional impairment affecting ADLs
Planned use of devices not supported by regulatory status without justification (e.g., metal‑on‑metal THA devices are not FDA‑approved)

Note

Medicare National Coverage

Medicare national coverage note — There is no Medicare national coverage determination (NCD) for total hip arthroplasty. Local Medicare coverage decisions (LCDs) or contractor policies may apply; for Medicare members, follow applicable Medicare contractor guidance in addition to this policy.

No Medicare NCD exists for THA
Check local coverage determinations and contractor medical policies for Medicare beneficiaries

Documentation Required

Device Documentation

Device and implant documentation — because implant regulatory status can affect coverage decisions, include planned device details in the request.

Document device manufacturer, model, and bearing surface
Note: there are no FDA‑approved metal‑on‑metal (MoM) total hip replacement devices marketed in the U.S.; if MoM or other non‑standard devices are planned, provide FDA status and justification

Key Definitions and Grading

Tonnis Classification — radiographic grading

DefinitionTonnis Classification grades radiographic hip osteoarthritis from grade 0 to grade 3.

Grade 0No signs of osteoarthritis.

Grade 3 (severe)Large cysts in the femoral head or acetabulum; severe joint space narrowing or obliteration; and severe deformity/loss of sphericity of the femoral head.

Total hip arthroplasty (THA) — definition and components

DefinitionTotal hip arthroplasty (THA) is surgical removal of diseased bone and cartilage of the hip and replacement with prosthetic implant components.

Major componentsFemoral component (stem and head) and acetabular component (shell and liner).

Materials and fixationImplant materials include ceramic, metal, or polyethylene; components may be cemented or press‑fit (uncemented).

Metal-on-metal (MoM) total hip implants — definition and regulatory status

DefinitionMetal-on-metal (MoM) total hip implants are total hip replacement devices with metal bearing surfaces.

FDA regulatory noteIn 2016 the FDA required premarket approval of all MoM total hip implants; manufacturers were required to stop marketing them pending PMA, and to date there are no FDA‑approved MoM total hip replacement devices marketed in the US.

Clinical concernUse of MoM bearings has been associated with local tissue reactions and higher revision rates (policy notes adverse outcomes with MoM).

Intra‑articular corticosteroid injection — definition and expected duration

DefinitionAn intra‑articular corticosteroid injection is an injection into the hip joint used for short‑term symptom relief when other pharmacologic treatments are ineffective or unsuitable.

Expected duration of reliefProvides short‑term symptom relief typically lasting about 2–10 weeks.

Role in conservative managementMay be used as part of a trial of non‑operative conservative management prior to considering surgery, as appropriate.

Policy Dates and Review

2019-09-01policy_created

New policy approved August 13, 2019 and effective January 1, 2020; hip arthroplasty considered medically necessary when criteria are met.

2020-03-01interim_review

Interim review approved February 20, 2020; added note that non-surgical management is not required if imaging shows bone-on-bone articulation.

2020-04-01deletion_notice

Policy scheduled for deletion effective July 2, 2020 and to be replaced with InterQual criteria for dates of service on or after July 2, 2020.

2020-07-02deletion_effective

Policy deletion noted (per prior notice).

2020-11-01policy_reinstated

Policy reinstated effective February 5, 2021 with references updated; policy statements unchanged.

2021-04-01annual_review

Annual review; policy reviewed and references updated; policy statements unchanged.

2022-03-01annual_review

Annual review approved February 21, 2022; references added and note that policy applies to adults 19 years and older.

2022-08-01interim_review

Interim review approved July 11, 2022 with minor edits and formatting for clarity; policy statements unchanged.

2023-04-01annual_review

Annual review approved March 20, 2023; added types of joint disease to be reviewed and minor editing/ reformatting for clarity.

2024-01-01interim_review

Interim review approved December 12, 2023 with minor corrections to align with Knee Arthroplasty policy; intent unchanged.

2024-11-01annual_review

Annual review approved October 7, 2024; references updated and minor formatting changes for clarity; policy statements unchanged.

2025-09-01annual_reviewLatest

Annual review approved August 25, 2025; policy reviewed with no references added and policy statements unchanged.

OpenPayer

Hip Arthroplasty in Adults (Total Hip Replacement)

Medical Necessity and Exclusions

Billing and Coding References

Prior Authorization, Documentation, and Provider Guidance

Clinical Background and Evidence

Key Definitions and Grading

Policy Dates and Review