| Printer Friendly Version |
| Medical Policy: | S-247-002 |
| Topic: | Total Hip and Total Knee Arthroplasty |
| Section: | Surgery |
| Effective Date: | July 30, 2018 |
| Issue Date: | July 30, 2018 |
| Last Reviewed: | April 2018 |
Total hip arthroplasty (THA) or replacement involves the removal of the femoral head and neck and replacing the damaged hip joint with a prosthesis. Hip prosthesis will consist of two to three components: (1) ball or head, (2) socket or acetabular component, and (3) femoral component or stem and components can be press fit into the bone or cemented in place. THA is used to provide pain relief and increase function. Total knee arthroplasty (TKA) involves the replacement of all of the surfaces of the knee. It includes the resection of all the diseased articular surfaces of the knee, and possibly normal condyles and the patella. This removal is followed by a resurfacing with metal and polyethylene prosthetic elements. All total knee arthroplasties consist of these three basic components: tibial, femoral, and patella. As with THA, TKA is also used to provide pain relief and restore function. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
THA may be considered medically necessary when ALL the following criteria are met:
- A diagnosis of advanced hip joint disease, supported by clinically appropriate (radiographic or MRI) imaging , and clinical diagnosis of at least ONE of the following:
- Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or
- Osteoarthritis (OA); or
- Rheumatoid arthritis (RA) or rheumatologic changes inconsistent with rehabilitation; or
- Avascular necrosis or osteonecrosis of femoral head; or
- Fracture of the femoral neck or acetabular fracture; or
- Mal-union of acetabular or proximal femur fracture; or
- Non-union or failure of previous hip fracture surgery; and
- Documentation of persistent pain that is not controlled despite optimal, conservative pain management:
- To include a description of the pain (onset, character, aggravating, duration, and relief factors), the analgesics and the treatment modalities used; and
- Documentation of functional limitations that interfere with activities of daily living (ADLs):
- To include the specific limitation of ADLs; and
- To include an evaluation of safety issues, e.g. fall risk; and
- Documentation of a history of conservative medical therapy that has been tried and failed, including, but not limited to TWO OR MORE of the following:
- Activity modification; or
- Physical therapy that includes flexibility and muscle strengthening exercises; or
- Assistive device use or walking aids; or
- Nonsteroidal anti-inflammatory drugs (NSAIDS); or
- Disease modifying antirheumatic drugs (DMARDS); or
- Therapeutic intra-articular (hip) injections as appropriate; or
- Weight loss efforts as appropriate.
NOTE: In the event that medical therapy is deemed inappropriate, the patient medical record is to indicate the rational and clinical circumstances precluding medical management.
THA will be considered contraindicated and not medically necessary for any other indication including, but not limited to the presence of the following:
- An infection of the hip joint or active systemic bacteremia; or
- An active skin infection or open wound within the planned surgical site of the hip; or
- Progressive neurological disease, with the exception of a clinically concomitant displaced femoral neck fracture; or
- Neurotrophic arthritis; or
- Allergy to any arthroplastic implant component; or
- Skeletal immaturity.
Revision or replacement of a THA may be covered for ANY of the following indications:
- Loosening of one or both of the arthroplastic implant components; or
- Mechanical failure or fracture of the implant; or
- Recurrent or irreducible dislocation; or
- Progressive or substantial bone loss; or
- Infection; or
- Adverse local tissue reaction; or
- Treatment of a displaced periprosthetic fracture; or
- Clinically significant inequality of leg length not amenable to conservative management; or
- Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; or
- Clinically significant audible noise.
TKA may be considered medically necessary when ALL of the following criteria are met:
- A diagnosis of advanced knee joint disease, supported by clinically appropriate (radiographic, or MRI) imaging , and clinical diagnosis of at least ONE of the following:
- Malignancy of the joint involving the soft tissues, or bones of the distal femur and/or the proximal tibia; or
- OA; or
- RA or rheumatologic changes inconsistent with rehabilitation; or
- Fracture of the distal femur or the proximal tibia; or
- Avascular necrosis or osteonecrosis of the knee; or
- Failure of a previous osteotomy or a unicompartmental knee replacement; and
- Documentation of persistent pain that is not controlled despite optimal, conservative pain management:
- To include a description of the pain (onset, character, aggravating, duration, and relief factors), analgesics and the treatment modalities used; and
- Documentation of functional limitations that interfere with ADLs:
- To include the specific limitation of ADLs;
- To include an evaluation of safety issues, e.g. fall risk; and
- Documentation of a history of conservative medical therapy that has been tried and failed including but not limited to TWO OR MORE of the following:
- Activity modification; or
- Physical therapy that includes flexibility and muscle strengthening exercises; or
- Assistive device use or walking aids; or
- NSAIDS; or
- DMARDS; or
- Therapeutic intra-articular (knee) injections as appropriate; or
- Weight loss efforts as appropriate; or
- Assessment of the stability of the ligature of the knee joint.
Knee arthroplasty will be considered contraindicated and not medically necessary for any other indications including, but not limited to, the presence of following:
- Active infection of the knee joint (e.g. active septic arthritis) or an active infectious process anywhere in the body (e.g. systemic bacteremia); or
- An open wound within the planned surgical site of the knee; or
- Progressive neurological disease; or
- Allergy to implant components; or
- Skeletal immaturity; or
- The presence of patient comorbid conditions that preclude the tolerance of operative stress such as anesthesia, and/or blood loss.
Revision or replacement of a TKA may be covered for ANY of the following indications:
- Loosening of one or both of the arthroplasty implant components; or
- Mechanical failure or fracture of a component of the implant; or
- Implant or knee misalignment; or
- Arthrofibrosis or knee stiffness; or
- Tibiofemoral instability; or
- Extensor mechanism instability; or
- Progressive or substantial periprosthetic bone loss; or
- Treatment for periprosthetic fracture of the distal femur, proximal tibia or patella; or
- Infection; or
- Adverse bone or local tissue reaction; or
- Bearing surface wear leading to symptomatic synovitis.
NOTE: For persons with significant conditions or co-morbidities, the risk/benefit of THA should be appropriately addressed in the medical record. If medical management is deemed inappropriate, the medical record should indicate the rationale for and circumstances under which this is the case. |
| Place of Service: Inpatient/Outpatient |
Total hip and total knee arthroplasty can be performed outpatient or inpatient.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Outpatient HCPCS (C Codes) |
| C1776 |
| Links |
- Link to Provider Resource Center for the Medical Policy Update
09/2017, New Policy Established for Total Hip and Total Knee Arthroplasty
05/2018, Place of Service Revised for Total Hip and Total Knee Arthroplasty
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
