CMM-311: Knee Replacement Arthroplasty

Cigna/EviCore covers medically necessary partial (medial, lateral, patellofemoral), post‑TKR patellofemoral, total, and revision knee arthroplasty for the specific indications listed and excludes procedures with specified contraindications or experimental devices (e.g., active local/systemic infection, vascular insufficiency ABI <0.5, inflammatory arthropathy, Charcot joint, significant tibial/femoral deformity or malalignment, patellar malalignment per Q‑angle/TT‑TG thresholds, and other listed exclusions). Key requirements include documented imaging/arthroscopic grading (Kellgren‑Lawrence III/IV or IV and/or Outerbridge/Modified Outerbridge Grade IV as applicable), function‑limiting pain and loss of ADLs for ≥3 months, failure of provider‑directed non‑surgical management for ≥3 months (or documented reason it’s inappropriate), specific exam findings (e.g., stability and ROM >90° for partial replacements), and comprehensive supporting documentation/imaging.