CMM-313: Hip Replacement/ Arthroplasty

Medically necessary hip procedures (partial and total hip resurfacing, partial and total hip replacement, revisions, isolated head/liner exchange, and salvage) are covered when indications are met; they are excluded for listed contraindications including active local/systemic infection, inadequate bone stock, osteonecrosis involving >50% of the femoral head, severe immunocompromise, Charcot joint, skeletal immaturity, uncontrolled medical conditions, and other specified exclusions. Coverage requires documented function‑limiting hip pain and functional loss, failure of provider‑directed non‑surgical management (generally ≥3 months, ≥6 months if BMI >40) unless non‑surgical care is inappropriate (must be clearly documented), fulfillment of specific radiographic/disease criteria (e.g., Tönnis grade, <50% femoral‑head involvement for AVN), age ≤64 for resurfacing, and documentation of risk/benefit and preoperative optimization for significant comorbidities.

"Partial hip resurfacing arthroplasty is considered medically necessary when ALL of the following criteria have been met: - Function-limiting pain at short distances (e."