CurrentuniverahealthcarePolicy 7.01.96

Hip Arthroplasty (partial and total hip replacement)

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Medical necessity criteria and exclusions for partial (hemi) and total hip replacement procedures; governs coverage determinations for members receiving hip arthroplasty.

Policy Summary

Payeruniverahealthcare

PolicyHip Arthroplasty (partial and total hip replacement)

Policy CodePolicy 7.01.96

Change TypeAnnual reviewminor revisions recorded

Effective DateOct 15, 2026

Last ReviewJun 18, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior authorization with imaging and documentation of function-limiting pain and ≥3 months of provider-directed non-surgical management (or documented exception).

SourceLink

POLICY UPDATE CHANGES

06/18/26 — Annual review; policy intent unchanged.

10/16/25 — Off cycle review. Removed 'and on a renal transplant list' from the not medically necessary indications for total hip.

06/26/25 — Annual review, policy statement regarding bilateral simultaneous hip replacement was removed from the policy.

3 monthsNon-surgical management minimum

Tönnis 2-3Imaging severity for THA

CollapseAVN imaging finding

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CurrentuniverahealthcarePolicy 7.01.96

Hip Arthroplasty (partial and total hip replacement)

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Medical necessity criteria and exclusions for partial (hemi) and total hip replacement procedures; governs coverage determinations for members receiving hip arthroplasty.

Policy Summary

Payeruniverahealthcare

PolicyHip Arthroplasty (partial and total hip replacement)

Policy CodePolicy 7.01.96

Change TypeAnnual reviewminor revisions recorded

Effective DateOct 15, 2026

Last ReviewJun 18, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior authorization with imaging and documentation of function-limiting pain and ≥3 months of provider-directed non-surgical management (or documented exception).

SourceLink

POLICY UPDATE CHANGES

06/18/26 — Annual review; policy intent unchanged.

10/16/25 — Off cycle review. Removed 'and on a renal transplant list' from the not medically necessary indications for total hip.

06/26/25 — Annual review, policy statement regarding bilateral simultaneous hip replacement was removed from the policy.

3 monthsNon-surgical management minimum

Tönnis 2-3Imaging severity for THA

CollapseAVN imaging finding

Revision indications count

MultipleExplicit contraindications

Coverage Criteria for Hip Arthroplasty

inv-01: Partial hip replacement — fracture — ANY of the following when ALL associated criteria are met

Partial hip replacement is medically necessary for ANY of the following when ALL associated criteria are met:

Femoral head/neck fracture: Imaging shows a fracture of the femoral head or femoral neck; and conservative management or surgical fixation is not considered a reasonable option.

chunks 3-4

inv-02: Partial hip replacement — AVN — ALL associated criteria (includes non-surgical trial requirement and imaging findings)

Partial hip replacement is medically necessary for AVN when ALL associated criteria are met:

Imaging evidence: Imaging that shows avascular necrosis (AVN) with collapse of the femoral head.

chunk 5

Symptoms: Function-limiting pain at short distances (e.g., walking less than one-quarter mile or ~2 city blocks) for at least three (3) months; and loss of hip function that interferes with age-appropriate activities of daily living or the demands of employment.>= 3 months of symptoms

chunks 6-7

Conservative therapy: Failure of at least three (3) months of provider-directed non-surgical management unless the medical record documents why non-surgical management is inappropriate (e.g., collapse of the femoral head, inflammatory arthritis, advanced dysplasia).>= 3 months

chunks 8-9

inv-03: Total hip replacement — fracture and degenerative/AVN/inflammatory indications — ANY of the following when ALL associated criteria are met

Total hip replacement is medically necessary for ANY of the following when ALL associated criteria are met:

Fracture: Imaging shows a fracture of the femoral head or femoral neck; and conservative management or surgical fixation is not considered a reasonable option.

chunks 16-17

Degenerative/AVN/Inflatory imaging: Imaging shows one of: Tönnis Grade 2-3 osteoarthritis; avascular necrosis with collapse of the femoral head; or inflammatory arthritis affecting both the femoral head and the acetabulum with joint space narrowing.

chunks 18-19,20

inv-04: Primary Total Hip Replacement - Medical Necessity Criteria — ALL of the following

Primary total hip replacement is medically necessary when ALL of the following are met:

Underlying diagnosis: Osteoarthritis, Avascular Necrosis (AVN), or Inflammatory Arthritis.

chunks 18-19

Imaging findings: One of: Tönnis Grade 2-3 osteoarthritis; avascular necrosis with collapse of the femoral head; inflammatory arthritis affecting both femoral head and acetabulum with joint space narrowing.

chunks 18-20

Symptoms: Both: function-limiting pain at short distances (e.g., walking less than one-quarter mile or ~2 city blocks) for at least three (3) months unless the medical record documents why non-surgical management is inappropriate; and loss of hip function interfering with age-appropriate activities of daily living or employment.>= 3 months (unless justified)

chunk 22

inv-05: Revision Hip Replacement - Indications — ANY of the listed postoperative conditions

Revision hip replacement (partial or total) is medically necessary when ANY of the following postoperative conditions are present:

Revision indications list: Recurrent prosthetic dislocation/subluxation unresponsive to provider-directed nonsurgical management; aseptic loosening; periprosthetic joint infection; periprosthetic fracture; instability of the implant (e.g., disassembly, modular neck failure); leg length discrepancy; osteolysis without eccentric wear (e.g., wear of elevated rim liner without superior wear).

chunks 31-37

inv-06: Medically Necessary Indications — specific indications for revision hip replacement

Revision of hip replacement is considered medically necessary for the following specific indications:

Approved indications: Revision is indicated for one or more of: leg length discrepancy; osteolysis without eccentric wear (e.g., wear of elevated rim liner without superior wear); elevated serum metal levels as a diagnostic indicator for adverse local tissue reaction (ALTR) secondary to corrosion; unexplained, function-limiting pain at short distances (e.g., walking < 1/4 mile or ~2 city blocks) persisting greater than six (6) months and unresponsive to provider-directed, non-surgical management.

chunks 36-39

inv-07: Not Medically Necessary — policy exclusions and 'not medically necessary' logic

Not medically necessary:

General exclusion: Revision of hip replacement is not medically necessary for any other indication or condition.

chunk 40

Partial hip replacement is not medically necessary for any indication or condition not specifically listed as medically necessary. It is also not medically necessary when any of the following contraindications are present: active local or systemic infection; vascular insufficiency, significant muscular atrophy of the leg, or neuromuscular disease severe enough to compromise implant stability or postoperative recovery; Charcot joint; or inflammatory arthritis affecting both the femoral head and the acetabulum.

Total hip replacement is not medically necessary for any indication or condition not explicitly identified as medically necessary. Additionally, a primary total hip replacement is not medically necessary when active local or systemic infection is present. Claims may also be denied if listed contraindications that compromise implant stability or recovery are documented.

Specific contraindications that render hip arthroplasty not medically necessary include: vascular insufficiency; significant muscular atrophy of the leg; and neuromuscular disease severe enough to compromise implant stability or postoperative recovery. In addition, for total hip replacement the policy lists individuals undergoing dialysis as a condition associated with noncoverage risk. These conditions should be documented in the medical record and will place the procedure at high risk for denial.

Revision hip replacement (partial or total) is not medically necessary for any indication or condition that is not specifically listed among the policy's medically necessary revision indications. If the clinical scenario does not match an approved revision indication, the request should be considered not medically necessary.

Coverage of hip arthroplasty services is contract dependent. If a product does not cover a specific service, the medical policy's clinical criteria do not apply. When a product does cover the service, the policy criteria guide coverage determinations and prior authorization requirements.

Partial hip replacement requests that do not meet the policy's listed medically necessary indications will be denied as not medically necessary. Denial conditions include the presence of any listed contraindication such as active infection, vascular insufficiency or significant muscular atrophy, neuromuscular disease compromising recovery, Charcot joint, or inflammatory arthritis affecting both the femoral head and acetabulum.

Primary total hip arthroplasty is not medically necessary when any of the policy's contraindications are present. Examples include active local or systemic infection, vascular insufficiency or significant muscular atrophy of the leg, neuromuscular disease severe enough to compromise implant stability or recovery, and situations such as patients undergoing dialysis that increase risk and may preclude benefit.

Requests for revision hip replacement will be considered not medically necessary if the clinical indication is not one of the postoperative conditions enumerated in the policy. The policy's approved revision indications must be met for coverage; otherwise the procedure should be denied.

Policy history: an off-cycle review on 10/16/25 revised the not medically necessary language by removing the phrase "and on a renal transplant list" from the total hip not medically necessary indications. This change was recorded in the policy revision history.

Coding and Timing Details

Covered CPT CodesCPTCovered

27125	Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
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

HCPCSHCPCS

No codes listed

ICD-10 Code RangesICD-10

M05.051-M08.959	Inflammatory polyarthropathies (hip) (code range)
M12.551-M12.559	Traumatic arthropathy, hip (code range)
M16.0-M16.9	Osteoarthritis of hip (code range)
M80.051A-M80.059S, M80.851A-M80.859S, M84.451A-M84.453S, M84.459A-M84.459S	Pathologic fracture of neck of femur (hip) (code ranges) and related
M87.051-M87.059, M87.151-M87.159, M87.251-M87.256	Atypical femoral fracture / Osteonecrosis of femur and thigh (code ranges)
M97.01XA-M97.02XS	(code range)
S72.001A-S72.26XS	Fracture of head and neck of femur (code range)

Relevant ICD-10 CodesICD-10

M05.051-M08.959	Inflammatory polyarthropathies (hip) (code range)
M12.551-M12.559	Traumatic arthropathy, hip (code range)
M16.0-M16.9	Osteoarthritis of hip (code range)
M80.051A-M80.059S	Pathologic fracture of neck of femur (hip) (code range)
M80.851A-M80.859S
M84.451A-M84.453S
M84.459A-M84.459S
M84.551A-M84.559S
M84.651A-M84.659S
M84.750A-M84.759S

1–10 of 18

1/2

inv-21: Non-surgical management trial duration (AVN partial hip) — minimum duration

Minimum trial durationAt least 3 months of provider-directed non-surgical management is required prior to partial hip replacement for AVN (unless an exception is documented)

Applies toAvascular necrosis (AVN) indications for partial hip replacement

Exception documentationMedical record must clearly document why non-surgical management is inappropriate to waive the 3-month requirement

inv-22: Duration of non-surgical management and pain — general minimum duration

Minimum durationAt least 3 months of function-limiting symptoms and failure of 3 months of provider-directed non-surgical management are generally required for consideration of primary total hip replacement

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

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.

Prior Authorization

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.

Background and Scope

Background: Hip arthroplasty includes partial (hemiarthroplasty) and total hip replacement. Indications covered by this policy include displaced femoral head or neck fractures, osteoarthritis with radiographic severity (e.g., Tönnis Grade 2-3), avascular necrosis with collapse of the femoral head, and inflammatory arthritis with joint space narrowing affecting both the femoral head and acetabulum. Clinical criteria require documentation of imaging findings and function-limiting symptoms, and generally a trial of conservative management before arthroplasty is approved.

Key Definitions and Imaging Criteria

inv-42: Collapse of the femoral head — imaging definition used as indication for replacement

DefinitionCollapse of the femoral head: imaging evidence of structural collapse of the femoral head used as an indication for partial or total hip replacement (e.g., AVN with collapse)

Used forSupports medical necessity for partial hip replacement (AVN) and primary total hip replacement when present on imaging

DocumentationImaging demonstrating femoral head collapse should be included with prior authorization and clinical records

inv-43: Tönnis Grade 2-3 — radiographic grading cited as imaging criterion supporting total hip replacement

Tönnis GradesGrade 2–3 per Tönnis classification (moderate to severe osteoarthritis) cited as radiographic criterion supporting total hip replacement

Grade descriptors

Policy Revision History

2026-06-18annual reviewLatest

Annual review; policy intent unchanged.

2025-10-16off-cycle review

Off-cycle review that removed 'and on a renal transplant list' from the not medically necessary indications for total hip.

2025-06-26annual review

Policy Summary

Payeruniverahealthcare

PolicyHip Arthroplasty (partial and total hip replacement)

Policy CodePolicy 7.01.96

Change TypeAnnual reviewminor revisions recorded

Effective DateOct 15, 2026

Last ReviewJun 18, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior authorization with imaging and documentation of function-limiting pain and ≥3 months of provider-directed non-surgical management (or documented exception).

SourceLink

On This Page

Conservative management: Failure of at least three (3) months of provider-directed non-surgical management, unless the medical record documents why non-surgical management is inappropriate.>= 3 months (unless justified)

ExceptionThree months is not required when the medical record documents why provider-directed non-surgical management is inappropriate

Documentation neededClinical notes should show both function-limiting pain >=3 months and unsuccessful non-surgical management for >=3 months (or rationale for exception)

inv-23: Duration of function-limiting pain — > 6 months threshold referenced

Threshold> 6 months of unexplained, function-limiting pain despite provider-directed non-surgical management is required before revision for pain

Operational contextApplies to unexplained, function-limiting pain at short distances (e.g., walking < 1/4 mile) unresponsive to non-surgical care

Documentation expectationMedical record should document duration >6 months and failed non-surgical management

Prior Authorization

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.

Prior Authorization

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.

Note

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.

Step Therapy

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).

Prior Authorization

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.

Documentation Required

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.

Note

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).

Documentation Required

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.

Documentation Required

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).

Documentation Required

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.

Documentation Required

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.

Denial Risk

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.

Denial Risk

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.

Denial Risk

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.

Billing Rule

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.

Grade 2: small cysts, moderate joint space narrowing, moderate loss of femoral head sphericity; Grade 3: large cysts, severe joint space narrowing or obliteration and severe deformity/loss of sphericity

Clinical useTönnis Grade 2–3 should be documented on imaging when used to justify primary THA

inv-44: Imaging findings supportive of primary THA — list of imaging criteria (Tönnis Grade 2-3; AVN with collapse; inflammatory arthritis)

Imaging criteria listOne of: Tönnis Grade 2–3 osteoarthritis; avascular necrosis with collapse of the femoral head; inflammatory arthritis affecting both the femoral head and acetabulum with joint space narrowing

PurposeThese imaging findings support medical necessity for primary total hip replacement

DocumentationRadiology reports should explicitly state which of these findings is present to support authorization

inv-45: Function-limiting pain — operational definition (limits walking distance to < 1/4 mile)

Operational definitionFunction-limiting pain: pain that limits walking to less than one-quarter mile (approximately two city blocks or length of a shopping mall)

Duration requirementFor primary THA, function-limiting pain should be present for at least 3 months unless an exception is documented; for revision considerations related to unexplained pain, it must persist >6 months and be unresponsive to non-surgical care

Associated loss of functionMust be accompanied by loss of hip function interfering with activities of daily living or employment when used to justify THA

inv-46: Total hip replacement definition — surgical components and fixation concept

Surgical componentsTotal hip replacement involves removal of the femoral head and neck and implantation of an artificial prosthesis composed of: (1) a head replacing the femoral head; (2) a femoral component (metal stem); and (3) an acetabular component

Fixation methodsThe femoral stem may be secured with bone cement or by press-fit to allow bone ingrowth

ScopeProcedure replaces the damaged hip joint with a prosthesis placed into the reamed femoral canal and implanted acetabulum

inv-47: Tonnis Classification — Grade 0-3 description

Grade 0No signs of osteoarthritis

Grade 1Sclerosis, slight joint space narrowing, osteophyte formation, no or slight loss of femoral head sphericity

Grade 2Small cysts in femoral head or acetabulum, moderate joint space narrowing, moderate loss of femoral head sphericity

Grade 3Large cysts, severe joint space narrowing or obliteration, severe deformity and loss of femoral head sphericity

inv-48: Relevant ICD-10 codes (definitions) — diagnosis code ranges relevant to hip arthroplasty

Osteoarthritis and inflammatory rangesM05.051–M08.959: Inflammatory polyarthropathies (hip); M16.0–M16.9: Osteoarthritis of hip

Avascular necrosis / osteonecrosisM87.151–M87.159; M87.251–M87.256: Osteonecrosis of femur and thigh (code ranges)

Fracture and pathologic fracture rangesS72.001A–S72.26XS: Fracture of head and neck of femur; M80.051A–M80.059S, M80.851A–M80.859S and related M84 ranges for pathologic/atypical femoral fractures

Annual review that removed the policy statement regarding bilateral simultaneous hip replacement.

2025-01-01process change

Summary of changes tracking implemented.

2018-06-21effective date

Original effective date of the policy.

2018-12-20history entry

Policy history entry recorded (12/20/18).

2019-06-20history entry

Policy history entry recorded (06/20/19).

2019-12-19history entry

Policy history entry recorded (12/19/19).

2020-12-17history entry

Policy history entry recorded (12/17/20).

2021-04-15history entry

Policy history entry recorded (04/15/21).

2022-04-21history entry

Policy history entry recorded (04/21/22).

2023-04-20history entry

Policy history entry recorded (04/20/23).

2024-10-17history entry

Policy history entry recorded (10/17/24).