Highmark Commercial Medical Policy - Pennsylvania
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:

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:

Revision or replacement of a THA may be covered for ANY of the following indications:

Procedure Codes
27090, 27091, 27130, 27132, 27134, 27137, 27138, 27236


TKA may be considered medically necessary when ALL of the following criteria are met:

Knee arthroplasty will be considered contraindicated and not medically necessary for any other indications including, but not limited to, the presence of following:

Revision or replacement of a TKA may be covered for ANY of the following indications:

Procedure Codes
27445, 27447, 27486, 27487, 27488


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




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: If you need these services, contact the Civil Rights Coordinator.

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.