CurrentPremera BluecrossPolicy 7.01.550

Knee Arthroplasty in Adults

Defines medical necessity, documentation, and coding requirements for total and unicompartmental knee arthroplasty in individuals aged 19 and older, and criteria for revisions/replacements. Applies to Premera Bluecross benefit determinations and provider pre-authorization submissions.

Policy Summary

PayerPremera Bluecross

PolicyKnee Arthroplasty in Adults

Policy CodePolicy 7.01.550

Change TypeAnnual review — no material change

Effective DateSep 1, 2025

Next Review DateSep 1, 2025

Key ActionObtain prior authorization and submit documentation of indications, imaging, and failed conservative therapy per policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19+age requirement (years)

≥3 momin nonop duration

KL 3–4radiographic severity

PT ≥12wPT requirement

27440–27447principal procedure codes

>19

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Coverage Criteria — Knee Arthroplasty

inv-01: Total or Unicompartmental Knee Arthroplasty - Initial

Covered when ALL of the following are met:

Age: Individual is aged 19 years or older>=19 years

Policy only applies to individuals aged 19 and older

Permitted diagnoses: Documented diagnosis of one of: degenerative joint disease (DJD), osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, or osteonecrosis

Symptoms and duration: Treatment is needed because of disabling pain for at least 3 months and/or functional disability interfering with activities of daily living>=3 months

Imaging evidence: Radiographic or imaging evidence of severe osteoarthritis (Kellgren-Lawrence grade 3 or 4) within 12 months prior to surgery, OR exposed subchondral bone (Outerbridge grade 4)KL grade 3 or 4 within 12 months

Radiology or imaging must be performed within 12 months prior to planned surgery

Conservative management: Documentation of failed non-operative conservative management demonstrated by: trial of one or more medications (NSAIDs oral or topical, acetaminophen, and/or intra-articular corticosteroid injection as appropriate) AND trial of one or more physical measures (physical therapy >= 12 weeks, flexibility and muscle strengthening exercises >= 12 weeks, or reasonable restriction of activities >= 12 weeks); NOTE: For Kellgren-Lawrence grade 4 (bone-on-bone) failure of a trial of physical measures is not requiredmedication trial and PT >=12 weeks (unless KL grade 4 with bone-on-bone)

See policy note that failure of physical measures is not required if imaging shows bone-on-bone articulation

inv-02: Replacement/Revision of Previous Arthroplasty

Knee arthroplasty replacement/revision may be medically necessary when ANY of the following are present:

Revision indications: Disabling pain; functional disability (limited knee function); progressive and substantial bone loss; fracture or dislocation of the patella; aseptic component instability or loosening; infection; periprosthetic fracture

inv-03: Other Specific Indications

Knee arthroplasty may be considered medically necessary for certain other diagnoses when detailed documentation supports the diagnosis:

Other indications: Distal femur fracture repair in an individual with osteoporosis; failure of a previous proximal tibial or distal femoral osteotomy; hemophilic arthroplasty; limb salvage for malignancy

Clinical records must document and support these diagnoses

inv-04: Coverage criteria and non-surgical treatment stance

Non-surgical treatment recommendations and historical policy criteria context relevant to knee arthroplasty decisions

Recommended Appropriate Treatments: For knee-only osteoarthritis without comorbidities, the policy lists biomechanical interventions, intra-articular corticosteroids, topical NSAIDs, walking cane, oral COX-2 inhibitors, capsaicin, oral non-selective NSAIDs, duloxetine, and acetaminophen as appropriate treatments.

From document recommended list.

Recommended Uncertain Treatments: Acupuncture, TENS, ultrasound, avocado soybean unsaponifiables (ASU), chondroitin, diacerein, glucosamine, hyaluronic acid (intra-articular injection), opioids (oral or transdermal), and rosehip are listed as uncertain treatments.

From document uncertain list.

Recommended Not Appropriate Treatments: Risedronate is listed as not appropriate for knee-only osteoarthritis without comorbidities.

From document not appropriate list.

This policy applies to individuals aged 19 years and older and does not apply to patellofemoral knee arthroplasty. All coverage criteria and documentation requirements described in the policy are intended for total knee and unicompartmental (partial) arthroplasty procedures and should not be used for patellofemoral-specific procedures.

Per the National Institute for Health and Care Excellence (NICE) guidance, intra-articular hyaluronan injections are not recommended for the management of osteoarthritis. NICE instead advises considering intra-articular corticosteroid injections as an adjunct to core treatments for short-term relief, and specifies that hyaluronan injections should not be offered for OA management.

For knee-only osteoarthritis in the absence of relevant comorbidities, the policy lists risedronate as a treatment considered not appropriate and therefore it should not be used as a therapy to meet conservative management requirements for isolated knee OA.

Coding and Procedure Codes

Covered CPT CodesCPTCovered

27440	Arthroplasty, knee, tibial plateau
27441	Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
27442	Arthroplasty, femoral condyles or tibial plateau(s), knee
27443	Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy
27445	Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)
27446	Arthroplasty, knee condyle and plateau; medial OR lateral compartment (unicompartmental or partial knee replacement)
27447	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
27486	Revision of total knee arthroplasty, with or without allograft; 1 component
27487	Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

Policy CPT codes referenced in historyCPT

27440	Total knee arthroplasty (code added to match policy criteria)
27441	Total knee arthroplasty (code added to match policy criteria)
27442	Total knee arthroplasty (code added to match policy criteria)
27443	Total knee arthroplasty (code added to match policy criteria)
27445	Total knee arthroplasty (previously removed then re-added in coding updates)

Conservative therapy duration — required trials

Physical measures durationPhysical therapy, flexibility/strengthening exercises, or activity restriction: ≥ 12 weeks

Medication/medical management durationTrial of one or more medications (NSAIDs or acetaminophen) and/or intra-articular corticosteroid injection for ≥ 3 months when pain is disabling

KL grade 4 exceptionFor Kellgren-Lawrence grade 4 (bone-on-bone), failure of a trial of physical measures is not required if imaging shows bone-on-bone

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Knee arthroplasty requires prior authorization by the health plan. Submit a completed prior authorization request before scheduling elective total or unicompartmental knee arthroplasty so the plan can review medical necessity.

Prior authorization must be obtained for elective total and unicompartmental knee arthroplasty
Include supporting medical records and imaging as described below when submitting the prior authorization request
Requests for replacement/revision arthroplasty also require prior authorization

Documentation Required

Documentation Needed for Medical Necessity

Medical records submitted for review must document that the individual's condition meets the policy's medical necessity criteria. Incomplete documentation is a common reason for delays or denial. Imaging must be current (performed within 12 months prior to planned surgery) and the report should be included with the prior authorization submission.

Background

Total knee arthroplasty involves replacement of diseased knee joint surfaces with prosthetic components to relieve pain and improve function in appropriately selected individuals who have failed nonoperative treatment. Unicompartmental (partial) knee arthroplasty may be considered when disease is limited to a single compartment. The policy requires documented diagnosis, evidence of disabling symptoms or functional limitation (≥ 3 months), and radiographic or imaging evidence of severe osteoarthritis (Kellgren‑Lawrence grade 3 or 4 within 12 months or Outerbridge grade 4) to establish medical necessity.

Definitions and Grading Scales

Kellgren-Lawrence grading

Grade 1Doubtful narrowing of joint space and possible osteophytic lipping

Grade 2Definite osteophytes and definite narrowing of joint space

Grade 3Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis, possible deformity of bone contour

Grade 4Large osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity of bone contour

Modified Outerbridge classification

Grade 1Focal areas of hyperintensity with normal contour (early changes)

Grade 2

Policy Summary

PayerPremera Bluecross

PolicyKnee Arthroplasty in Adults

Policy CodePolicy 7.01.550

Change TypeAnnual review — no material change

Effective DateSep 1, 2025

Next Review DateSep 1, 2025

Key ActionObtain prior authorization and submit documentation of indications, imaging, and failed conservative therapy per policy.

SourceLink

On This Page

Guideline recommendations (NICE): NICE recommends considering intra-articular corticosteroid injections as an adjunct to core treatments for short-term relief (about 2–10 weeks) and does not recommend intra-articular hyaluronan injections for the management of osteoarthritis.

Guideline summary from NICE cited in document.

Conservative management historical note: Historically the policy required one or more medical measures and physical measures unless symptoms were severe and radiographic evidence of advanced OA was present; refer to current policy for the specific conservative management criteria and prior authorization rules.

Derived from policy history entries describing conservative management changes.

Include radiology/imaging reports from studies performed within 12 months of planned surgery
Document diagnosis, duration and severity of symptoms, and prior conservative treatments
For osteoarthritis, provide imaging evidence consistent with Kellgren-Lawrence grade 3–4 or Outerbridge grade 4 as applicable

Step Therapy

Conservative Therapy Trial Requirement

To show that nonoperative care was unsuccessful, include documentation of a trial of conservative therapies. Failure to document the required trials or to show imaging demonstrating advanced disease increases the risk of denial.

Document at least 3 months of failed nonoperative conservative management for Kellgren-Lawrence grade 3 disease, including one or more medical measures (NSAIDs, acetaminophen, and/or intra-articular corticosteroid injection) and one or more physical measures (physical therapy ≥12 weeks, flexibility/strengthening exercises ≥12 weeks, or reasonable activity restriction ≥12 weeks)
For Kellgren-Lawrence grade 4 (bone-on-bone) imaging, failure of a physical-measures trial is not required but documentation of medical measures attempted is expected
Specify dates, duration, and response (or lack of response) to each conservative therapy attempted

Denial Risk

Triggers for Potential Denial

Common triggers that may lead to denial include absent or outdated imaging, lack of documented conservative therapy when required, and missing clinical details demonstrating disabling pain or functional limitation. Prior history notes in policy updates emphasize these documentation-related denial risks.

No imaging within 12 months showing Kellgren-Lawrence grade 3–4 (or equivalent)
No documentation of at least 3 months of failed conservative management when required
Insufficient documentation of disabling pain or functional limitation interfering with ADLs
Missing radiology report or incomplete medical records submitted with the prior authorization

Documentation Required

Required Documentation and Documentation-Related Denial Risk

Provide complete clinical documentation with the prior authorization request to minimize denial risk. The plan historically has required submission of radiology reports performed within 12 months; include those reports and records showing conservative care attempts and functional limitations.

Clinical history and diagnosis (e.g., OA, DJD, RA, traumatic arthritis, osteonecrosis)
Description of disabling pain and/or functional disability affecting ADLs, including symptom duration (≥3 months when applicable)
Imaging reports performed within 12 months demonstrating severity (Kellgren-Lawrence grade 3–4 or Outerbridge grade 4/chondromalacia grade 4) with descriptive findings
Detailed documentation of conservative treatments tried (medications, injections) with dates and durations, and physical measures (PT, exercises, activity restriction) with durations
For revisions: documentation supporting indications (infection, aseptic loosening, progressive bone loss, fracture, instability, periprosthetic fracture, etc.)

Cartilage softening and swelling, blister-like swelling/fraying or fragmentation/fissuring

Grade 3Partial-thickness cartilage loss with focal ulceration or fibrillation

Grade 4Full-thickness cartilage loss with exposed subchondral bone (cartilage destruction exposing bone)

Knee arthroplasty

DefinitionSurgical replacement of knee joint surfaces with metal and plastic prosthetic components (total or unicompartmental)

PurposeReplace diseased articular surfaces to relieve pain and improve function in appropriately selected individuals

ComponentsArtificial joint attached to femur, tibia, and patella using metal and plastic prostheses

Intra-articular corticosteroid injections

Role in managementConsidered an adjunct to core treatments for relief of moderate to severe OA pain

Expected benefit durationProvide short-term relief (approximately 2 to 10 weeks) per guideline guidance

Use in policy criteriaMay be included among medication trials required to demonstrate failed conservative management prior to arthroplasty

Intra-articular hyaluronan (hyaluronan) injections

Guideline stanceNICE does not recommend offering intra-articular hyaluronan injections for the management of osteoarthritis

ImplicationHyaluronan injections are not supported by NICE for OA management and are listed as not recommended in guideline summaries

Policy contextDocument cites NICE guidance to support non-use of intra-articular hyaluronan for OA