CMM-311: Knee Replacement/Arthroplasty

Partial, primary total, and revision knee arthroplasty (including isolated polyethylene exchange) are medically necessary when the guideline’s specific clinical, functional, radiographic/arthroscopic and failure-of-conservative-therapy criteria are met, while numerous contraindications and procedures designated experimental/unproven (e.g., bicompartmental arthroplasty, UniSpacer, CPTs 27437/27440–27443) are excluded. Key requirements include documented function‑limiting pain at short distances and loss of ADLs for ≥3 months (≥6 months if BMI >40), objective imaging or arthroscopic evidence of severe disease or AVN (Kellgren‑Lawrence Grade IV or Outerbridge Grade IV as applicable), failure of provider‑directed non‑surgical management for the required timeframe, intact/stable ligaments and >90° ROM for unicompartmental cases, and specific documentation for revisions/IPE (infection timing, progressive osteolysis, implant failure, etc.).

"For revision/IPE: imaging demonstrating progressive osteolysis and confirmation of well-fixed implants in acceptable position when IPE is requested for wear/osteolysis."