Document fracture imaging and failed/unsuitable fixation

Prior authorization must include imaging that documents a fracture of the femoral head or femoral neck and indicate that conservative management or surgical fixation is not considered a reasonable option for the fracture.

• Include radiology reports or images showing femoral head/neck fracture.
• Document why conservative treatment or fixation is not appropriate.

Include imaging showing collapse or Tönnis Grade 2–3

For AVN, OA, or inflammatory arthritis indications, prior authorization must include imaging evidence such as collapse of the femoral head (AVN) or Tönnis Grade 2–3 osteoarthritis, plus clinical documentation of function-limiting symptoms.

• Imaging demonstrating AVN with femoral head collapse or Tönnis Grade 2–3 OA.
• Clinical notes documenting function-limiting pain and loss of hip function.

Confirm required imaging findings and clinical failure in prior auth

Prior authorization submissions must confirm imaging findings that meet policy criteria (one of: Tönnis Grade 2–3; AVN with femoral head collapse; or inflammatory arthritis with joint space narrowing) and document function‑limiting pain and failure of conservative management unless an exception is justified.

• State which imaging criterion is met and attach supporting images/reports.
• Provide documentation of function‑limiting pain and non‑surgical management attempts or documented exception.

Obtain prior auth for listed hip arthroplasty CPT codes

Prior authorization is expected for the hip arthroplasty CPT codes listed in the policy; include clinical documentation tied to the requested CPT code(s) and applicable diagnosis codes.

• Covered CPT codes include 27125, 27130, 27132, 27134, 27137, 27138.
• Link each requested procedure code to the supporting clinical and imaging documentation.

Verify product coverage before prior authorization

Confirm that the member’s product covers the service before relying on the policy; prior authorization and policy criteria apply only when the product benefit includes the service.

• If a product does not cover the service, medical policy criteria do not apply and the claim may be denied.
• If coverage is through Medicare or Medicaid, follow the product‑specific guidance noted in the policy.

Document ≥3 months of provider‑directed non‑surgical management for AVN

Document an adequate trial of provider‑directed non‑surgical management of at least three (3) months for AVN prior to partial hip replacement unless the medical record clearly documents why non‑surgical management is inappropriate.

• Record duration and specifics of non‑surgical treatments and their outcomes.
• If an exception is claimed, document the clinical reason (see exception documentation block).

Require documentation of failed ≥3‑month non‑surgical trial before primary THA

Prior authorization and clinical records must show failure of at least three (3) months of provider‑directed non‑surgical management before primary total hip arthroplasty, unless the medical record documents why non‑surgical management is inappropriate.

• Attach records describing the non‑surgical modalities attempted and dates.
• If an exception is documented, include the clinical justification and supporting imaging.

Document non‑surgical management trial prior to revision when indicated

For revision procedures, document an adequate trial of provider‑directed non‑surgical management where indicated (e.g., unexplained, function‑limiting pain) prior to consideration of revision surgery.

• Provide evidence of non‑surgical treatments tried and duration when revision is sought for persistent pain or dysfunction.
• Document reasons for proceeding to revision when non‑surgical management was not feasible or unsuccessful.

No explicit step therapy pathway specified

The policy does not define explicit step therapy pathways; do not rely on a step‑therapy algorithm from this policy when preparing prior authorization — instead follow the documented non‑surgical management and exception guidance.

• No specific stepwise sequence is mandated in the policy text.
• Document the specific non‑surgical interventions used (see examples block).

Document reasons when claiming exception to non‑surgical management

If non‑surgical management is considered inappropriate, the medical record must clearly document the reason (for example, collapse of the femoral head, inflammatory arthritis, or advanced dysplasia) to support an exception to the ≥3‑month requirement.

• Describe the clinical rationale and attach supporting imaging or specialist opinions.
• State explicitly which exception from the policy is being applied and why.

Provide required clinical documentation of pain duration and failed conservative care

Required clinical documentation for prior authorization should demonstrate function‑limiting pain for at least three (3) months and failure of at least three (3) months of provider‑directed non‑surgical management, or clearly document why non‑surgical management is inappropriate.

• Include history of symptom duration, functional limitations, and prior treatments.
• Attach imaging that meets the policy’s imaging criteria (e.g., Tönnis Grade, AVN collapse).

List prior non‑surgical management attempts and responses

Document prior non‑surgical management interventions such as activity modification, weight loss, medications, assistive devices, and intra‑articular injections when submitting prior authorization or claims.

• List specific treatments, dates, and response to each modality.
• Include notes on functional impact and objective measures where available.

Cross‑reference and document applicable Medicare LCD/LCA

When Medicare is the payer, reference and document alignment with applicable CMS local coverage determinations (e.g., LCD L36039 and LCA A57428) as noted in the policy.

• Attach or cite the relevant LCD/LCA when Medicare coverage is claimed.
• Explain how the case meets both the policy criteria and any applicable Medicare local guidance.

Avoid submission when listed contraindications are present (denial risk)

Partial hip replacement and total hip replacement claims will be denied if any listed contraindications are present; ensure the medical record confirms absence of active local or systemic infection, vascular insufficiency, significant muscular atrophy, neuromuscular disease compromising implant stability or recovery, Charcot joint, or inflammatory arthritis affecting both femoral head and acetabulum.

• Explicitly document infection status and vascular/neuromuscular exam findings.
• If any contraindication is present, do not submit as medically necessary per this policy.

Document absence of contraindications for primary THA to avoid denial

Claims for total hip replacement may be denied if documented contraindications exist (active infection; vascular insufficiency, significant muscular atrophy, neuromuscular disease compromising implant stability or recovery; or if the individual is undergoing dialysis).

• Confirm and document absence of these contraindications before requesting authorization.
• If the member is on dialysis or has severe neuromuscular disease, include specialist consultation explaining risk/benefit if proceeding.

Do not submit revisions for indications outside policy — risk of denial

Revision procedures are not considered medically necessary for indications not listed in the policy; ensure the reason for revision matches one of the policy’s approved indications.

• Approved revision indications are listed in the policy and must be documented (e.g., aseptic loosening, periprosthetic infection, periprosthetic fracture, implant instability).
• If the indication is not listed, expect denial.

Verify contract/product coverage to prevent denials

Services are contract dependent; verify benefit coverage before submission because if the product excludes the service, the policy criteria do not apply and the claim may be denied.

• Confirm benefit coverage with eligibility/benefit or payer prior to scheduling surgery or requesting authorization.
• If product does not cover service, do not submit under this policy.