CMM-311: Knee Replacement/Arthroplasty

Covered: partial (medial, lateral, patellofemoral) unicompartmental, total, revision knee arthroplasty and isolated polyethylene liner exchange are medically necessary only for specified indications and excluded for other uses or listed experimental/unproven procedures. Key requirements: documented imaging/arthroscopic severity (Kellgren‑Lawrence/Outerbridge/Modified Outerbridge or AVN), usually knee stability and >90° arc of motion, function‑limiting symptoms ≥3 months with ≥3 months of failed provider‑directed non‑surgical care (or documented why non‑surgical care is inappropriate), plus detailed preop documentation; specific exclusions include active infection, inflammatory arthropathy, Charcot joint, significant vascular insufficiency, defined deformity thresholds, certain dialysis/transplant candidates, and other listed contraindications.

"Revision of knee replacement - Post-operative stiffness due to component sizing or positioning."