CurrentUnivera HealthcarePolicy 7.01.123

Orthopedic Joint Procedures of the Knee for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members

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Medical-necessity coverage criteria for orthopedic knee procedures, including knee arthroplasty and related procedures, for Managed Medicaid, HARP, Child Health Plus, and Essential Plan members.

Policy Summary

PayerUnivera Healthcare

PolicyOrthopedic Joint Procedures of the Knee

Policy CodePolicy 7.01.123

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateSeptember 1, 2027

Key ActionBefore total knee arthroplasty, document failed conservative therapy, including at least 6 weeks of physical therapy in the past 6 months plus at least one additional treatment.

SourceLink

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CurrentUnivera HealthcarePolicy 7.01.123

Orthopedic Joint Procedures of the Knee for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members

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Sign up for univerahealthcare Policy 7.01.123 alerts

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Medical-necessity coverage criteria for orthopedic knee procedures, including knee arthroplasty and related procedures, for Managed Medicaid, HARP, Child Health Plus, and Essential Plan members.

Policy Summary

PayerUnivera Healthcare

PolicyOrthopedic Joint Procedures of the Knee

Policy CodePolicy 7.01.123

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateSeptember 1, 2027

Key ActionBefore total knee arthroplasty, document failed conservative therapy, including at least 6 weeks of physical therapy in the past 6 months plus at least one additional treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤40 kg/m²BMI limit

6 weeksPhysical therapy

12+ weeksPain duration

3–6 monthsRadiograph recency

1+Additional treatment

20Inpatient risk factors

Medical Necessity Criteria

Total Knee Arthroplasty

Covered when ALL of the following are met:

ALL of the following

BMI 40 kg/m² or less.
Pain results in functional impairment that limits range of motion and interferes with activities of daily living.
EITHER
- Conservative treatment requirements
  - Failure of conservative therapy to improve symptoms or functional status.
  - A physical therapy program, including telehealth-based rehabilitation when appropriate, provided by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.>= 6 weeks in the past 6 months
  - At least ONE treatment
    Modification of activity, protective weight-bearing, or use of an orthotic.
    Intra-articular corticosteroid injection.
    Medication management.
- Conservative treatment requirements do not apply when ANY of the following are present
  - Osteonecrosis/avascular necrosis (AVN).
  - Malignancy involving the knee or adjacent structures.
  - Distal femur or proximal tibia malunion/nonunion fracture.
  - Failed partial knee arthroplasty.
  - Severe deformity, condylar collapse, or end-stage bone-on-bone disease.

Qualifying Knee Condition

The qualifying knee condition includes EITHER of the following:

EITHER

Disease has progressed into an uninvolved compartment.
ALL of the following
- Arthritic condition includes ANY
  - Osteoarthritis.
  - Inflammatory arthropathy.
  - Post-traumatic arthritis.
- Knee pain causing loss of function for 12 weeks or more that interferes with activities of daily living.

Site-of-Service Requirements

Site of service requirements are met for EITHER of the following:

EITHER

Outpatient, when ANY of the following are met
- No history of narcotic use.
- No active cardiopulmonary disease.
- ASA Physical Status Classification 1–2.
Inpatient, when perioperative risk factors are present.

Inpatient Setting Based on Perioperative Risk Factors

An inpatient setting is required when ANY of the following perioperative risk factors are present:

ANY of the following

Congestive heart failure.
Chronic atrial fibrillation that is not adequately controlled.
Transient ischemic attack (TIA) or stroke within the preceding three months.
Diabetes mellitus with HbA1c greater than 8% within the last 90 days.
Stage 4 or 5 chronic kidney disease.
Age 80 years or older.

Inpatient Perioperative Risk Factors

Inpatient perioperative risk factors include ANY of the following:

ANY of the following

Congestive heart failure.
Chronic atrial fibrillation that is not adequately controlled.
TIA or stroke within the preceding three months.
Diabetes mellitus with HbA1c greater than 8% within the last 90 days.
Stage 4 or 5 chronic kidney disease.
Age 80 years or older.

Revision Total Knee Arthroplasty

Covered when ALL of the following are met:

ALL of the following

BMI less than 40 kg/m².
Pain results in functional impairment that limits range of motion and interferes with activities of daily living.
Prosthetic failure and/or removal requirement due to infection.
Weight-bearing radiographs within the last 3 to 6 months or physical examination demonstrate ONE or more
- Aseptic loosening.
- Component instability.

Revision Total Knee Arthroplasty Criteria

ALL of the following

BMI less than 40 kg/m².
Pain causes functional impairment limiting range of motion and interfering with activities of daily living.
Prosthetic failure and/or removal due to infection.
Radiographs or examination demonstrate aseptic loosening, component instability or failure, prosthetic recall, osteolysis, periprosthetic infection or fracture, or recurrent instability, dislocation, or subluxation.

Partial or Unicompartmental Knee Arthroplasty

Partial or unicompartmental knee arthroplasty is medically necessary when documentation supports ALL of the following:

ALL of the following

The remaining knee compartments do not demonstrate degenerative changes.
The anterior cruciate ligament is functional through native integrity or prior successful reconstruction/repair.
ONE qualifying condition
- Advanced unicompartmental osteoarthritis.
- Isolated medial or lateral compartment osteoarthritis (Kellgren-Lawrence grade III or IV).
- Post-traumatic arthritis limited to a single compartment.

PKA or UKA Medical Necessity Criteria

PKA or UKA is medically necessary when ALL of the following are met:

ALL of the following

BMI requirement
- BMI 40 kg/m² or less.
- If BMI is 40 kg/m² or greater, documented weight reduction of at least 10% before surgery.
Failure of conservative therapy to improve symptoms or functional status, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.
Pain for at least 12 weeks has resulted in functional impairment limiting range of motion and interfering with activities of daily living or causing painful weight-bearing.
Physical examination consistent with advanced unicompartmental disease

PKA or UKA Radiographic Criterion

ANY of the following

Severe narrowing of the affected compartment joint space.
Bone-on-bone contact confined to a single compartment.
Moderate-to-severe osteoarthritic degeneration (Kellgren-Lawrence grade III or IV) within the last 3 to 6 months.

Patellofemoral Arthroplasty Medical Necessity

A patellofemoral knee arthroplasty (PFA) is medically necessary when ALL of the following are met:

ALL of the following

BMI is 40 kg/m² or less.
ONE qualifying condition
- Unsuccessful outcome following a patellofemoral extensor mechanism unloading procedure.
- Severe patellofemoral osteoarthritis (Kellgren-Lawrence grade III or IV) limited to a single knee compartment.

Patellofemoral Arthroplasty Medical Necessity Criteria

ALL of the following

The remaining compartments do not demonstrate degenerative changes.
Severe patellofemoral osteoarthritis is limited to a single compartment.
Isolated anterior or patellar knee pain persists for at least 3 months and is exacerbated by stairs, inclines, transfers, or prolonged sitting.
Pain for at least 12 weeks causes functional impairment or painful weight-bearing.
Failure of conservative therapy, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.
Physical examination includes ONE or more

Diagnostic Knee Arthroscopy

Diagnostic knee arthroscopy is medically necessary when documentation supports ALL of the following:

ALL of the following

Weight-bearing radiographs do not demonstrate moderate-to-severe osteoarthritic degeneration (Kellgren-Lawrence grade III or IV), including anteroposterior and Rosenberg views when available.
Pain for at least 12 weeks causes functional impairment limiting range of motion and interfering with activities of daily living or painful weight-bearing.
Failure of conservative therapy, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.

Diagnostic Knee Arthroscopy Criteria

ALL of the following

Diagnostic studies have failed to establish a definitive diagnosis, including plain radiographs and MRI.
Physical examination includes ONE or more
- Joint swelling or effusion.
- Restricted range of motion.
- Positive meniscal provocation examination consistent with joint-line tenderness.

Arthroscopic Chondroplasty

Arthroscopic chondroplasty of the knee is medically necessary when ALL of the following are met:

ALL of the following

Failure of conservative therapy, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.
Weight-bearing radiographs within the previous 3 to 6 months demonstrate minimal degenerative joint disease, consistent with Kellgren-Lawrence grade 0 or I.
Knee pain causes functional impairment interfering with activities of daily living, work-related activities, routine ambulation, athletics, or other age-appropriate activities.
Mechanical symptoms during weight-bearing activity
- Painful clicking or popping.

Arthroscopic Chondroplasty Criteria

ALL of the following

Minimal degenerative joint disease on recent weight-bearing radiographs (Kellgren-Lawrence grade 0 or I).
Pain causes functional impairment.
ANY of the following
- Painful clicking or popping.
- Recurrent catching.
- True mechanical locking or limitation of joint motion.

Debridement for Arthrofibrosis

Debridement, with or without chondroplasty, is medically necessary when documentation supports the indication and associated criteria:

ALL of the following

Arthrofibrosis is present.
Weight-bearing radiographs do not demonstrate moderate-to-severe osteoarthritic changes (Kellgren-Lawrence grade III or IV).
Clinical findings are consistent with arthrofibrosis, including pain, stiffness, and restricted range of motion.
A physical therapy program, including telehealth-based rehabilitation when appropriate, was provided by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.

Debridement of Femoral Condyle or Tibial Plateau Articular Cartilage

Debridement of femoral condyle or tibial plateau articular cartilage is medically necessary when ALL of the following are met:

ALL of the following

Absence of moderate-to-severe osteoarthritis on weight-bearing radiographs.
Failure of conservative therapy includes ALL
- Use of an orthotic or brace.
- A physical therapy program, including telehealth-based rehabilitation when appropriate, provided by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.
- At least ONE treatment
  - Intra-articular corticosteroid injection.

Patellofemoral Chondrosis Requirement

Patellofemoral chondrosis requires no evidence of an alternative pain generator, including referred pain, bursitis, radicular pain, or tendinopathy.

Patellofemoral Chondrosis Criteria

Patellofemoral chondrosis is medically necessary when ALL of the following are met:

ALL of the following

No alternative pain generator
- No referred pain.
- No bursitis.
- No radicular pain.
- No tendinopathy.
Weight-bearing radiographs do not demonstrate moderate-to-severe osteoarthritis (Kellgren-Lawrence grade III or IV).
Failure of conservative therapy includes ALL

Osteochondritis Dissecans (Pediatric Population)

Osteochondritis dissecans in the pediatric population is medically necessary when ALL of the following are met:

ALL of the following

At least TWO clinical findings
- Restricted range of motion.
- Limping.
- Locking or catching symptoms.
- Joint pain, particularly during or after activity.
- Joint swelling.

Pediatric Osteochondritis Dissecans Criteria

ALL of the following

At least TWO clinical findings
- Restricted range of motion.
- Limping.
- Locking or catching symptoms.
- Joint pain, particularly during or after activity.
- Joint swelling.
- Localized tenderness.

Removal of Loose Body or Foreign Body

Arthroscopic or open removal of an intra-articular loose body or foreign body of the knee is medically necessary when ALL of the following are met:

ALL of the following

Symptoms are present
- Pain.
- Pain is accompanied by ONE or more
  - Buckling during weight-bearing activities.
  - Instability or weakness.
  - Mechanical symptoms including clicking, popping, catching, or locking.
Imaging requirement

Loose or Foreign Body Removal Criteria

ALL of the following

Symptoms include pain with buckling, instability or weakness, or mechanical clicking, popping, catching, or locking.
Recent knee radiographs or MRI document the condition.
ANY of the following
- Intra-articular loose body.
- Foreign body within the knee joint.
- Impinging osteophyte contributing to symptoms.

Hemarthrosis

Hemarthrosis is a qualifying indication when BOTH are met:

ALL of the following

Associated with trauma, coagulation disorder, or bleeding disorder.
Diagnosis confirmed by physical examination, joint aspiration, MRI, or a combination of these.

Symptomatic Synovial Plica

Symptomatic synovial plica is medically necessary when ALL of the following are met:

ALL of the following

Examination and MRI findings support the diagnosis of plica.
Conservative therapy failed to improve symptoms contributing to loss of function or functional status, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain treatment, or intra-articular corticosteroid injection.
Joint aspiration or corticosteroid injection has been performed when clinically appropriate.

Proliferative Synovial Disease

Proliferative synovial disease is medically necessary when ALL of the following are met:

ALL of the following

Condition includes ONE or more
- Pigmented villonodular synovitis (PVNS).
- Synovial chondromatosis.
- Sarcoid synovitis.
- Traumatic hypertrophic synovitis.
- Similar proliferative synovial disorder.

Proliferative Synovial Disease Criteria

ALL of the following

Condition includes PVNS, synovial chondromatosis, sarcoid synovitis, traumatic hypertrophic synovitis, or a similar proliferative synovial disorder.
Conservative therapy failed, including physical therapy for at least 6 weeks in the past 6 months and at least one activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain treatment, or intra-articular corticosteroid injection.
Diagnosis is confirmed by biopsy, MRI, clinical history, or a combination of these.

Rheumatoid Synovitis

Rheumatoid synovitis is medically necessary when ALL of the following are met:

ALL of the following

Rheumatoid arthritis with symptomatic synovial involvement.
Conservative therapy failed, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain treatment, or intra-articular corticosteroid injection.
Disease remains refractory following at least 6 months of disease-modifying antirheumatic drug (DMARD) therapy.>= 6 months

Pediatric/Skeletally Immature ACL Reconstruction

ACL reconstruction is medically necessary in pediatric or skeletally immature individuals when ALL of the following are met:

ALL of the following

At least TWO of the following are present
- Audible pop at the time of injury.
- Difficulty achieving full knee extension.
- Instability during cutting, pivoting, jumping, or athletic activities.
- Localized joint tenderness.
- Pain with weight-bearing activities.

Documentation and Denial Risks

Documentation Required

Revision Arthroplasty Documentation

For revision total knee arthroplasty, document the qualifying revision indication and supporting examination or imaging findings.

Recurrent instability, dislocation, or subluxation documented by weight-bearing radiographs from the previous 3–6 months or physical examination.

Documentation Required

Partial Knee Arthroplasty Documentation

For partial or unicompartmental knee arthroplasty, documentation must establish that the remaining compartments are preserved and the ACL is functional.

Remaining knee compartments do not demonstrate degenerative changes.
ACL is functional through native integrity or prior successful reconstruction or repair.

Policy Background

Total knee arthroplasty is considered medically necessary when knee pain causes substantial functional impairment, including limited range of motion and interference with activities of daily living, and the applicable clinical, imaging, and treatment requirements are met. The policy generally requires a BMI of 40 kg/m² or less, documented failure of conservative therapy including physical therapy for at least 6 weeks in the past 6 months plus at least one additional treatment, and evidence of qualifying knee disease. For the usual arthritic pathway, pain must cause functional loss for 12 weeks or more, with weight-bearing radiographs obtained within the last 3 to 6 months showing advanced degenerative joint disease, such as bone-on-bone contact in two or more compartments, marked joint-space narrowing, or Kellgren-Lawrence grade III or IV. The conservative-treatment requirement does not apply when specified serious conditions are present, including osteonecrosis or avascular necrosis, malignancy involving the knee or adjacent structures, distal femur or proximal tibia malunion or nonunion fracture, failed partial knee arthroplasty, or severe deformity, condylar collapse, or end-stage bone-on-bone disease.

Procedure Definitions

Partial or Unicompartmental Knee Arthroplasty

DefinitionA partial knee arthroplasty (PKA) or unicompartmental knee arthroplasty (UKA) replaces or treats a single knee compartment.

Extent of treatmentThe procedure addresses one knee compartment rather than the entire knee.

Policy terminologyThe policy uses partial knee arthroplasty (PKA) and unicompartmental knee arthroplasty (UKA) for this single-compartment treatment.

Proliferative Synovial Disease

DefinitionProliferative synovial disease is a group of proliferative synovial disorders identified in the policy.

Qualifying disordersThe condition includes one or more of the following: pigmented villonodular synovitis (PVNS), synovial chondromatosis, sarcoid synovitis, traumatic hypertrophic synovitis, or a similar proliferative synovial disorder.

Policy Summary

PayerUnivera Healthcare

PolicyOrthopedic Joint Procedures of the Knee

Policy CodePolicy 7.01.123

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateSeptember 1, 2027

Key ActionBefore total knee arthroplasty, document failed conservative therapy, including at least 6 weeks of physical therapy in the past 6 months plus at least one additional treatment.

SourceLink

On This Page

Weight-bearing radiographs within the last 3 to 6 months demonstrate advanced degenerative joint disease including ONE or more

Bone-on-bone contact involving two or more knee compartments.
Marked narrowing of the joint space.
Moderate-to-severe osteoarthritic changes (Kellgren-Lawrence grade III or IV).

Proximal femoral or adjacent soft tissue malignancy.

History of alcohol withdrawal seizures or delirium tremens.

Evidence of active drug toxicity manifested by physiologic instability, such as tachycardia, hypertension, or electrocardiographic abnormalities.

ASA Physical Status Classification greater than 3.

Proximal femoral or adjacent soft tissue malignancy.

History of alcohol withdrawal seizures or delirium tremens.

Active drug toxicity with physiologic instability, such as tachycardia, hypertension, or electrocardiographic abnormalities.

ASA Physical Status Classification greater than 3.

Periprosthetic infection.

Periprosthetic fracture.

Recurrent instability, dislocation, or subluxation.

Contracture.
Crepitus.
Correctable angular deformity: valgus 20 degrees or less or varus 15 degrees or less.
Joint swelling or effusion.
Instability.
Restricted range of motion.

Recent knee radiographs demonstrate ONE or more

Severe narrowing of the affected compartment joint space.
Bone-on-bone contact confined to a single compartment.
Moderate-to-severe osteoarthritic degeneration (Kellgren-Lawrence grade III or IV) within the last 3 to 6 months.

Contracture.
Crepitus.
Deformity.
Joint swelling or effusion.
Patellar instability.
Restricted range of motion.

Weight-bearing radiographs confirm BOTH

No degenerative changes in the lateral or medial compartments.
ANY of the following
- Severe narrowing of the patellofemoral joint space.
- Patellofemoral bone-on-bone contact confined to a single compartment.

True mechanical locking or limitation of joint motion.

Medication management.

Recurrent joint effusions, with two or more episodes.

MRI within the previous 3 to 6 months demonstrates an unstable chondral lesion.

Knee pain has resulted in functional impairment.

Use of an orthotic or brace.
A physical therapy program, including telehealth-based rehabilitation when appropriate, provided by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.
At least ONE treatment
- Intra-articular corticosteroid injection.
- Medication management.

Anterior knee pain localized to the patellofemoral compartment.

Functional limitation attributable to patellofemoral symptoms.

Localized tenderness.

Imaging conducted within the previous 3 to 6 months includes both radiographs and MRI.

Radiographs and MRI obtained within the previous 3 to 6 months.

Failure of conservative therapy includes ALL

Use of an orthotic or brace.
Physical therapy provided by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.
At least ONE failure factor
- Lesion size greater than 150 mm².
- Lesion extending into shoulders or talus.
- Limited remaining skeletal growth potential.
- Unstable or detached osteochondral lesion.

Knee radiographs obtained within the previous 3 to 6 months.

MRI obtained within the previous 3 to 6 months.

Indication

Intra-articular loose body.
Foreign body within the knee joint.
Impinging osteophyte contributing to symptoms.

Conservative therapy failed to improve symptoms contributing to loss of function or functional status, including physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain treatment, or intra-articular corticosteroid injection.

Quadriceps muscle atrophy.

Conservative Treatment Before Arthroplasty

Document failure of conservative therapy before arthroplasty. The record must show both a qualifying rehabilitation program and at least one additional treatment.

Physical therapy, including appropriate telehealth rehabilitation, provided by a physical therapist or chiropractor for at least 6 weeks during the past 6 months.
At least one: activity modification/protective weight-bearing/orthotic use; intra-articular corticosteroid injection; or medication management.

Step Therapy

Failure of Conservative Therapy

Document that conservative therapy failed to improve symptoms or functional status, including the specific interventions, dates, duration, and response.

At least 6 weeks of qualifying physical therapy in the past 6 months.
At least one additional conservative treatment: activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.

Step Therapy

Failed Conservative Treatment for Partial Arthroplasty

Partial knee arthroplasty requires documentation of failed conservative treatment and the required duration and components of therapy.

Physical therapy by a physical therapist or chiropractor for at least 6 weeks in the past 6 months, including telehealth rehabilitation when appropriate.
At least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.

Step Therapy

Failed Conservative Therapy for Patellofemoral Arthroplasty

Patellofemoral arthroplasty requires documentation that conservative treatment failed to improve symptoms or functional status.

Physical therapy for at least 6 weeks in the past 6 months by a physical therapist or chiropractor.
At least one of activity modification/protected weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.

Step Therapy

Required Conservative Treatment Before Arthroscopy

Before diagnostic arthroscopy or chondroplasty, document the required conservative treatment course and failure to improve symptoms or function.

Physical therapy by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.
At least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.

Step Therapy

Failed Conservative Treatment for Cartilage Debridement

Cartilage debridement requires documented failure of the complete conservative regimen before the procedure.

Use of an orthotic or brace.
Physical therapy for at least 6 weeks in the past 6 months.
At least one of intra-articular corticosteroid injection or medication management.

Step Therapy

Failed Conservative Therapy for Synovial Conditions

For synovial conditions, document failed conservative therapy and the treatments actually attempted.

Physical therapy for at least 6 weeks in the past 6 months.
At least one of activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain management, or intra-articular corticosteroid injection.
For rheumatoid synovitis, document the additional DMARD requirement.

Step Therapy

DMARD Therapy Requirement

Rheumatoid synovitis requires documentation that symptomatic disease remains refractory after the required DMARD trial.

At least 6 months of disease-modifying antirheumatic drug therapy with persistent refractory disease.

Documentation Required

Total Knee Arthroplasty Medical-Necessity Documentation

Total knee arthroplasty requests must include complete medical-necessity documentation addressing BMI, functional impairment, conservative treatment, clinical severity, imaging, and site of service.

BMI is 40 kg/m² or less.
Pain causes functional impairment limiting range of motion and interfering with activities of daily living.
Document failure of the required conservative therapy.
Document qualifying clinical and imaging findings and the applicable outpatient or inpatient setting.

Documentation Required

Conservative Treatment History

Document the complete conservative treatment history supporting total knee arthroplasty.

Physical therapy for at least 6 weeks in the past 6 months.
At least one of activity modification/protective weight-bearing/orthotic use, intra-articular corticosteroid injection, or medication management.
Document failure to improve symptoms or functional status.

Documentation Required

Clinical and Imaging Documentation

Clinical and imaging documentation must establish symptomatic advanced degenerative knee disease.

Knee pain causing loss of function for at least 12 weeks and interfering with activities of daily living.
Weight-bearing radiographs within the last 3–6 months show advanced degenerative joint disease, including moderate-to-severe osteoarthritis (Kellgren-Lawrence grade III or IV).

Documentation Required

Outpatient Site-of-Service Documentation

Document why the requested total knee arthroplasty will be performed in an eligible outpatient setting.

Outpatient criteria may include no history of narcotic use and ASA Physical Status Classification 1–2.
If outpatient criteria are not met, document the applicable inpatient risk factor.

Documentation Required

Inpatient Perioperative Risk Documentation

When inpatient arthroplasty is requested, document the perioperative risk factor supporting inpatient care.

Examples include congestive heart failure or stage 4 or 5 chronic kidney disease.
Document the relevant diagnosis, severity, and perioperative impact.

Documentation Required

Revision Clinical and Imaging Documentation

Revision arthroplasty requests require documentation of functional impairment and a qualifying revision cause.

Pain limits range of motion and interferes with activities of daily living.
Weight-bearing radiographs from the last 3–6 months or physical examination demonstrate a qualifying finding such as aseptic loosening.

Documentation Required

Revision Examination or Imaging

For revision arthroplasty, document the qualifying imaging or examination finding rather than relying on the revision diagnosis alone.

Weight-bearing radiographs within the last 3–6 months or physical examination demonstrate recurrent instability, dislocation, or subluxation.

Documentation Required

Partial Knee Compartment and ACL Documentation

Partial knee arthroplasty documentation must establish isolated compartment disease and a functional ACL.

The remaining knee compartments do not demonstrate degenerative changes.
The ACL is functional through native integrity or prior successful reconstruction or repair.

Documentation Required

Clinical Eligibility Documentation

Document all clinical eligibility elements for partial or unicompartmental knee arthroplasty.

BMI is 40 kg/m² or less, or if BMI is 40 kg/m² or greater, documented weight reduction is at least 10% before surgery.
Pain for at least 12 weeks causes functional impairment, limits range of motion, interferes with activities of daily living, or causes painful weight-bearing.
Examination and recent radiographs demonstrate advanced isolated unicompartmental disease, including severe narrowing of the affected compartment.

Documentation Required

Patellofemoral Clinical and Imaging Documentation

Patellofemoral arthroplasty requires complete clinical and imaging documentation.

Pain for at least 12 weeks causes functional impairment or painful weight-bearing.
Document failure of conservative therapy.
Examination may show contracture; weight-bearing radiographs show no medial or lateral compartment degeneration and either severe patellofemoral joint-space narrowing or single-compartment patellofemoral bone-on-bone contact.

Documentation Required

Diagnostic Arthroscopy Medical Necessity

Diagnostic knee arthroscopy requires documentation of the medical-necessity criteria, including imaging, symptoms, failed conservative therapy, and unresolved diagnostic uncertainty.

Radiographs do not show moderate-to-severe osteoarthritis (Kellgren-Lawrence grade III or IV).
Pain for at least 12 weeks causes functional impairment or painful weight-bearing.
Conservative therapy failed and the required physical therapy plus additional treatment were completed.

Documentation Required

Diagnostic Arthroscopy Documentation

Document the complete diagnostic arthroscopy criteria and the failure of conventional diagnostic studies to establish a definitive diagnosis.

Include plain radiographs and other conventional diagnostic studies as applicable.
Document intra-articular pathology on examination, such as joint swelling or effusion.
Document the required symptoms, conservative treatment failure, and absence of advanced radiographic degeneration.

Documentation Required

Chondroplasty Documentation

Chondroplasty requires documentation of minimal radiographic degeneration, functional pain, failed conservative therapy, and mechanical symptoms.

Weight-bearing radiographs within the previous 3–6 months are consistent with Kellgren-Lawrence grade 0 or I.
Pain interferes with activities of daily living, work, ambulation, athletics, or age-appropriate activities.
Document the required physical therapy and at least one additional conservative treatment.

Documentation Required

Mechanical Symptoms for Chondroplasty

Document qualifying mechanical symptoms during weight-bearing activity for arthroscopic chondroplasty.

Painful clicking or popping.
Recurrent catching.
True mechanical locking or limitation of joint motion.

Documentation Required

Arthrofibrosis Documentation

Arthrofibrosis documentation must establish the clinical diagnosis and exclude advanced osteoarthritis.

Weight-bearing radiographs do not demonstrate moderate-to-severe osteoarthritis (Kellgren-Lawrence grade III or IV).
Clinical findings are consistent with arthrofibrosis, including pain, stiffness, and restricted range of motion.
Physical therapy was provided for at least 6 weeks in the past 6 months.

Documentation Required

Cartilage Debridement Documentation

Cartilage debridement requests must document every required criterion; incomplete conservative-treatment or lesion documentation creates denial risk.

No moderate-to-severe osteoarthritis on weight-bearing radiographs.
Failed conservative therapy including orthotic/brace use, at least 6 weeks of physical therapy, and intra-articular corticosteroid injection or medication management.
At least two joint effusions, an MRI-demonstrated unstable chondral lesion within 3–6 months, and functionally impairing knee pain.

Documentation Required

Patellofemoral Chondrosis Documentation

Patellofemoral chondrosis requires documentation that no alternative pain generator explains the symptoms.

Document absence of referred pain and other alternative pain generators.

Documentation Required

Recent Diagnostic Imaging

Removal of a loose body or foreign body requires recent diagnostic imaging.

Knee radiographs or MRI obtained within the previous 3–6 months.

Documentation Required

Qualifying Symptoms

Document qualifying symptoms for removal of an intra-articular loose body or foreign body.

Pain with buckling during weight-bearing, instability or weakness, or mechanical clicking, popping, catching, or locking.

Step Therapy

Failed Conservative Treatment for Pediatric OCD

Pediatric osteochondritis dissecans requires documentation of failed nonoperative treatment and risk factors for failure.

At least two symptoms: activity-related joint pain, swelling, or localized tenderness.
Radiographs and MRI obtained within the previous 3–6 months.
Orthotic/brace use, physical therapy for at least 6 weeks in the past 6 months, and at least one risk factor such as lesion size greater than 150 mm², extension into shoulders or talus, limited skeletal growth, or an unstable/detached lesion.

Documentation Required

Hemarthrosis Documentation

Hemarthrosis documentation must establish both the underlying association and the diagnosis.

Associated with trauma, a coagulation disorder, or a bleeding disorder.
Diagnosis confirmed by physical examination, joint aspiration, MRI, or a combination.

Documentation Required

Symptomatic Plica Documentation

Symptomatic plica requires documented diagnosis, failed conservative therapy, and appropriate procedural management.

Examination and MRI support the plica diagnosis.
Physical therapy for at least 6 weeks in the past 6 months.
At least one of activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain treatment, or intra-articular corticosteroid injection; aspiration or injection performed when clinically appropriate.

Documentation Required

Proliferative Synovial Disease Documentation

Proliferative synovial disease requires documentation of the disease type, failed conservative treatment, and functional impact.

Document PVNS, synovial chondromatosis, sarcoid synovitis, traumatic hypertrophic synovitis, or a similar proliferative synovial disorder.
Physical therapy for at least 6 weeks in the past 6 months and at least one of activity modification/protected weight-bearing/brace/orthotic use, pharmacologic pain treatment, or intra-articular corticosteroid injection.
Symptoms contribute to loss of function or functional status.

Documentation Required

Confirm Diagnosis

Confirm the proliferative synovial disease diagnosis using the required clinical or diagnostic evidence.

Diagnosis confirmed by biopsy, MRI, clinical history, or a combination of these.

Documentation Required

Document Physical Therapy

Document physical therapy as part of conservative treatment for symptomatic synovial conditions.

Physical therapy, including appropriate telehealth rehabilitation, provided by a physical therapist or chiropractor for at least 6 weeks in the past 6 months.

Documentation Required

Document DMARD Treatment Failure

For rheumatoid synovitis, document failure of the required DMARD treatment in addition to other conservative measures.

Disease remains refractory after at least 6 months of DMARD therapy.
Also document physical therapy and at least one additional conservative treatment.

Documentation Required

Pediatric ACL Findings

Pediatric ACL reconstruction requires at least two qualifying clinical findings in a skeletally immature individual.

Document at least two: audible pop at injury, difficulty achieving full extension, instability with cutting/pivoting/jumping or athletic activity, localized tenderness, weight-bearing pain, or quadriceps atrophy.

Denial Risk

BMI Exceeds Arthroplasty Limit

Total knee arthroplasty is not medically necessary when BMI exceeds the policy limit.

BMI greater than 40 kg/m², absent the policy's separate qualifying documentation for an applicable procedure.

Denial Risk

Insufficient Functional Impairment

Deny or pend the request when functional impairment is not adequately documented.

Pain must limit range of motion and interfere with activities of daily living or otherwise meet the applicable functional-pain requirement.

Denial Risk

Conservative Therapy Criteria Not Met

Conservative therapy criteria are not met when the required rehabilitation duration or treatment components are absent.

Missing physical therapy for at least 6 weeks in the past 6 months.
Missing at least one additional qualifying treatment.

Denial Risk

Conservative Therapy Failure Not Established

Failure of conservative therapy is not established without documented lack of improvement after the required treatments.

Record the treatments attempted, dates and duration, adherence, and persistent symptoms or functional limitations.

Denial Risk

Insufficient Clinical or Radiographic Severity

Do not approve arthroplasty when the record lacks sufficient clinical or radiographic severity.

Document the required duration and functional impact of pain.
Provide recent weight-bearing imaging showing the applicable advanced or compartment-specific degenerative findings.

Denial Risk

Site-of-Service Criteria Not Met

The requested site of service must satisfy the applicable outpatient or inpatient criteria.

Outpatient requests require the applicable low-risk criteria, such as no narcotic history and ASA 1–2.
If those criteria are not met, document a qualifying inpatient perioperative risk factor such as CHF or stage 4–5 chronic kidney disease.

Denial Risk

Active Infection Contraindication

Active local or systemic infection is a contraindication to total knee arthroplasty.

Do not proceed until infection is appropriately evaluated and resolved.

Denial Risk

Uncontrolled Medical Conditions or Infection

Total knee arthroplasty is not medically necessary with uncontrolled diabetes, uncontrolled hypertension, or another clinically unstable or unmanaged comorbidity.

Uncontrolled diabetes includes HbA1c greater than 8%.
Document stabilization and management before surgery.

Denial Risk

Recent Tobacco, Injection, or Unstable Comorbidity

Recent nicotine or tobacco use, a recent operative-joint injection, or an unstable comorbidity creates contraindication or denial risk.

Nicotine or tobacco use within 6 weeks of surgery is contraindicating.
Intra-articular corticosteroid injection within 12 weeks of surgery is contraindicating.
Clinically unstable or unmanaged comorbid conditions are contraindicating.

Denial Risk

Implant Allergy or Unmanaged Substance Use Disorder

Implant-incompatible allergy or untreated substance use disorder is a contraindication to total knee arthroplasty.

Material allergy must be compatible with implantation.
Substance use disorder must be treated or managed.

Denial Risk

Contraindicating Bone Density Conditions

Osteoporosis or osteopenia contraindicates partial or unicompartmental knee arthroplasty.

Document bone density status when clinically relevant.

Denial Risk

Bone Disease, Infection, or Uncontrolled Diabetes

Partial or unicompartmental knee arthroplasty is contraindicated with bone disease, active infection, or uncontrolled diabetes.

Osteoporosis or osteopenia.
Active local or systemic infection.
Uncontrolled diabetes mellitus, including HbA1c greater than 8%.

Denial Risk

Recent Nicotine Use or Corticosteroid Injection

Recent nicotine or tobacco use and recent corticosteroid injection in the operative joint contraindicate partial or unicompartmental arthroplasty.

Nicotine or tobacco use within 6 weeks before surgery.
Intra-articular corticosteroid injection in the operative joint within 12 weeks before surgery.

Denial Risk

Compartment Meniscectomy or Angular Deformity

A total meniscectomy in the remaining compartment or excessive angular deformity contraindicates partial or unicompartmental arthroplasty.

Total meniscectomy in the remaining compartment.
Fixed valgus deformity greater than 20 degrees or fixed varus deformity greater than 15 degrees.

Denial Risk

Contracture, Limited Flexion, or Unmanaged Comorbidity

Excessive contracture or limited flexion, or an unstable or unmanaged comorbidity, contraindicates partial or unicompartmental arthroplasty.

Flexion contracture of at least 15 degrees.
Flexion less than 110 degrees.
Clinically unstable or unmanaged comorbid condition.

Denial Risk

Implant Allergy or Unmanaged Substance Use Disorder

An implant-incompatible material allergy or untreated or unmanaged substance use disorder contraindicates partial or unicompartmental arthroplasty.

Document implant compatibility and management of any substance use disorder.

Denial Risk

Patellofemoral Arthroplasty Contraindications

Patellofemoral arthroplasty is contraindicated when infection or other listed clinical conditions are present.

Active local or systemic infection.
Abnormal patellofemoral alignment or tracking.
Uncontrolled diabetes or hypertension, inflammatory arthritis, ligament-deficiency instability, or fixed flexion contracture of 10 degrees or more.

Denial Risk

Patellofemoral Active Infection

Active local or systemic infection contraindicates patellofemoral arthroplasty.

Document infection evaluation and resolution before surgery.

Denial Risk

Abnormal Patellofemoral Tracking

Abnormal patellofemoral alignment or tracking contraindicates patellofemoral arthroplasty.

Document alignment and tracking on examination or imaging.

Denial Risk

Uncontrolled Diabetes

Uncontrolled diabetes contraindicates patellofemoral arthroplasty.

HbA1c greater than 8% is identified as uncontrolled diabetes.

Denial Risk

Uncontrolled Hypertension

Uncontrolled hypertension contraindicates patellofemoral arthroplasty.

Document blood-pressure control before surgery.

Denial Risk

Inflammatory Arthritis

Inflammatory arthritis contraindicates patellofemoral arthroplasty.

Document the arthritis diagnosis when evaluating eligibility.

Denial Risk

Ligament-Deficiency Instability

Knee instability related to ligament deficiency contraindicates patellofemoral arthroplasty.

Document ligament status and stability on examination.

Denial Risk

Recent Nicotine or Tobacco Use

Nicotine or tobacco use within 6 weeks before surgery contraindicates patellofemoral arthroplasty.

Includes cigarettes, cigars, e-cigarettes, nicotine patches, smokeless tobacco, and vape pens.

Denial Risk

Recent Corticosteroid Injection

An intra-articular corticosteroid injection in the operative joint within 12 weeks before surgery contraindicates patellofemoral arthroplasty.

Document the injection date and operative joint.

Denial Risk

Total Meniscectomy

Total meniscectomy in the remaining compartment contraindicates patellofemoral arthroplasty.

Document meniscal history and the status of the remaining compartment.

Denial Risk

Unmanaged Comorbid Conditions

A clinically unstable or unmanaged comorbid condition contraindicates patellofemoral arthroplasty.

Document management and stabilization of relevant comorbidities.

Denial Risk

Implant-Incompatible Allergy

A material allergy incompatible with implantation contraindicates patellofemoral arthroplasty.

Document implant-material compatibility or an appropriate management plan.

Denial Risk

Unmanaged Substance Use Disorder

An untreated or unmanaged substance use disorder contraindicates patellofemoral arthroplasty.

Document treatment or management before surgery.

Denial Risk

Fixed Flexion Contracture

A fixed flexion contracture of 10 degrees or more contraindicates patellofemoral arthroplasty.

Document the measured degree of fixed contracture.

Denial Risk

Missing Diagnostic Arthroscopy Criteria

Diagnostic arthroscopy is not medically necessary when the required documentation is incomplete.

Missing qualifying symptoms, absence of advanced osteoarthritis, failed conservative therapy, unresolved diagnostic uncertainty, or intra-articular examination findings may result in denial.

Denial Risk

Missing Chondroplasty Criteria

Chondroplasty is not medically necessary when the required conservative, imaging, pain, or mechanical-symptom criteria are missing.

Document minimal radiographic degeneration, functionally impairing pain, failed conservative therapy, and qualifying mechanical symptoms.

Denial Risk

Arthrofibrosis Criteria Not Met

Arthrofibrosis criteria are not met without the required imaging, clinical findings, and physical therapy documentation.

Radiographs must exclude moderate-to-severe osteoarthritis.
Document pain, stiffness, restricted range of motion, and at least 6 weeks of physical therapy in the past 6 months.

Denial Risk

Cartilage Debridement Criteria Not Met

Cartilage debridement criteria are not met when any required clinical, imaging, lesion, effusion, or conservative-treatment element is absent.

Required elements include no moderate-to-severe osteoarthritis, orthotic or brace use, physical therapy for at least 6 weeks, injection or medication management, at least two effusions, recent MRI evidence of an unstable chondral lesion, and functional pain.

Denial Risk

No Qualifying Loose-Body Indication

Loose-body or foreign-body removal is not medically necessary without a qualifying indication.

Document an impinging osteophyte contributing to symptoms or another listed indication.

Denial Risk

Hemarthrosis Criteria Not Established

Hemarthrosis criteria are not established without both an accepted association and diagnostic confirmation.

Document trauma, coagulation disorder, or bleeding disorder.
Confirm the diagnosis by examination, aspiration, MRI, or a combination.

Denial Risk

Incomplete Plica Criteria

Plica criteria are incomplete when diagnosis, conservative-treatment failure, or clinically appropriate aspiration/injection documentation is missing.

Examination and MRI must support plica.
Document physical therapy for at least 6 weeks and at least one additional conservative treatment.
Document aspiration or corticosteroid injection when clinically appropriate.

Denial Risk

Proliferative Synovial Disease Criteria Not Met

Proliferative synovial disease criteria are not met without a qualifying disorder, failed conservative therapy, and functional impact.

Qualifying disorders include PVNS, synovial chondromatosis, sarcoid synovitis, traumatic hypertrophic synovitis, or a similar disorder.
Document physical therapy for at least 6 weeks, an additional conservative treatment, and symptoms affecting function.

Denial Risk

Recent Intra-Articular Corticosteroid Injection

Arthroscopic knee procedures are contraindicated when an intra-articular corticosteroid injection was administered too recently.

Injection within 4 weeks of the planned arthroscopic procedure.

Denial Risk

Incomplete Proliferative Synovial Disease Criteria

Proliferative synovial disease criteria are incomplete when the diagnosis is not confirmed or the conservative-treatment requirements are missing.

Confirm diagnosis by biopsy, MRI, clinical history, or a combination.
Document physical therapy for at least 6 weeks and at least one qualifying additional treatment.

Denial Risk

Incomplete Rheumatoid Synovitis Criteria

Rheumatoid synovitis criteria are incomplete without symptomatic rheumatoid involvement, failed conservative therapy, and refractory disease after DMARD treatment.

Document symptomatic rheumatoid synovitis.
Document physical therapy for at least 6 weeks and at least one additional conservative treatment.
Disease must remain refractory after at least 6 months of DMARD therapy.

Denial Risk

Insufficient Pediatric ACL Findings

Pediatric ACL reconstruction is not medically necessary when fewer than two qualifying findings are documented.

Qualifying findings include audible pop at injury, difficulty achieving full extension, activity-related instability, localized tenderness, weight-bearing pain, or quadriceps atrophy.

Minimum qualifying conditionAt least one of the listed proliferative synovial disorders must be present.