CMM-311: Knee Replacement/Arthroplasty

Covered: partial (medial, lateral, patellofemoral) unicompartmental knee replacement, total knee replacement, revision arthroplasty and isolated polyethylene liner exchange when the policy’s specific indications are met; excluded/not medically necessary: bicompartmental/bi‑unicompartmental arthroplasty, arthroscopic/open abrasion arthroplasty and listed contraindications (e.g., active infection, severe deformity, instability, inadequate bone stock, Charcot, uncontrolled comorbidities). Key requirements: documented function‑limiting pain and loss of ADLs for ≥3 months (≥6 months if BMI>40) with failure of provider‑directed nonsurgical care or documentation why it’s inappropriate, appropriate radiographic/arthroscopic severity (Kellgren‑Lawrence/Outerbridge grades as specified), required stability and ROM thresholds (eg, >90° for partial/patellofemoral), and preoperative optimization and supporting documentation for revisions/IPE.

"Partial knee replacement (medial, lateral, or patellofemoral unicompartmental) is considered medically necessary when ALL of the following criteria are met: - Function-limiting pain at short distan..."