Does 27125 require prior authorization?

No, 27125 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 27125?

Medicare facility rate: $1035.76. Non-facility rate: $1035.76. Work RVU: 16.22.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

16.22

Facility

$1035.76

Non-Facility

$1035.76

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews.
Complete diagnostic interpretation of imaging findings including, at a minimum: relevant clinical information, detailed report of imaging findings, impression, and specialty(ies) of the provider(s) who interpreted the images. (Updated wording in Medical Records Documentation Used for Review.)
Clinical documentation that would be relevant to applying InterQual® clinical criteria (e.g., symptom description, prior conservative treatment, physical exam findings, patient-reported outcome measures such as WOMAC, HOOS, iHOT-33) may be requested to determine whether criteria for medical necessity are met.

Surgery of the hip and surgical treatment for Femoroacetabular Impingement (FAI) Syndrome is proven and medically necessary in certain circumstances.
For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures: Arthroscopy, Diagnostic, +/- Synovial Biopsy, Hip; Arthroscopy, Surgical, Hip; Arthroscopy, Surgical, Hip (Pediatric); Arthrotomy, Hip; Hemiarthroplasty, Hip; Removal and Replacement, Total Joint Replacement (TJR), Hip; Total Joint Replacement (TJR), Hip.
Surgical treatment for Femoroacetabular Impingement (FAI) Syndrome (including procedures such as arthroscopy with femoroplasty (29914), acetabuloplasty (29915), labral repair (29916), and related hip arthroscopy/arthroplasty procedures) when clinical criteria for medical necessity are met as defined by the referenced InterQual® criteria.
anatomic patellofemoral inlay resurfacing
UniCAP as an alternative for unicompartmental arthritis
robotic-arm assisted total knee arthroplasty

CARELON-joint-surgery-2024-11-17-updated-2025-01-01 — Joint Surgery

CARELON-level-of-care-for-surgical-procedures-2025-11-15 — Level of Care for Surgical Procedures

UHC-POL-surgery-hip — Surgery of the Hip

UMR-POL-UMR-surgery-hip — Surgery of the Hip

SUREST-POL-SUREST-surgery-hip — Surgery of the Hip

Ask Verity about documentation requirements, denial risks, or coverage in your state.