CMM-311: Knee Replacement/Arthroplasty

Partial, total, and revision knee arthroplasty and isolated polyethylene liner exchange are covered when specific indications are met, while procedures listed as experimental/investigational and cases with contraindications (e.g., active local/systemic infection, inadequate bone stock, severe fixed deformity or instability not amenable to correction, uncontrolled comorbidities, severe immunocompromise, Charcot joint, vascular insufficiency) are excluded. Coverage requires documented function‑limiting pain for ≥3 months (≥6 months if BMI >40) with loss of function, radiographic (Kellgren‑Lawrence IV) or arthroscopic (Outerbridge IV) evidence when required, failure of provider‑directed non‑surgical management (or documented inappropriateness), and procedure‑specific findings (e.g., intact/stable ligaments and >90° ROM for unicompartmental replacement; documentation of implant status/indication for revisions or IPE).

"Imaging/advanced imaging: refer to MS-12: Osteoarthritis and MS-25: Knee for the advanced imaging indications prior to knee replacement surgery (imaging documentation as indicated by those referenc..."