Does 27415 require prior authorization?

No, 27415 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 27415?

Medicare facility rate: $1258.55. Non-facility rate: $1258.55. Work RVU: 19.50.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

19.50

Facility

$1258.55

Non-Facility

$1258.55

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
Updated imaging documentation requirement: "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"
Medical Records Documentation Used for Reviews (general): medical records documentation used for reviews to determine whether member meets clinical criteria (note: documentation does not guarantee coverage)
Documentation that an adequate autologous graft is not available (e.g., prior autograft already used) when tendon allograft is being considered for ACL reconstruction (text: "Tendon allograft for reconstruction of the ACL should only be employed when an adequate autologous graft is not available").

Surgery of the knee is proven and medically necessary in certain circumstances (see InterQual® CP: Procedures).
Refer to InterQual® CP: Arthroscopy or Arthroscopically Assisted Surgery, Knee
Refer to InterQual® CP: Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
Refer to InterQual® CP: Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee
Refer to InterQual® CP: Arthrotomy, Knee
Refer to InterQual® CP: Arthrotomy, Knee (Pediatric)

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-knee — Surgery of the Knee

UMR-POL-UMR-surgery-knee — Surgery of the Knee

SUREST-POL-SUREST-surgery-knee — Surgery of the Knee

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