CMM-313: Hip Replacement/ Arthroplasty

Medically necessary: partial and total hip resurfacing/arthroplasty, partial and total hip replacement, revisions, isolated head/liner exchange and salvage procedures when there is function‑limiting hip pain and loss of function (typically ≥3 months; ≥6 months of provider‑directed non‑surgical management if BMI >40), appropriate weight‑bearing radiographs showing joint‑space narrowing when required, and procedure‑specific findings (e.g., fractures, Tönnis Grade 3 OA, osteonecrosis <50% for resurfacing; age ≤64 for resurfacing). Not covered/contraindicated: procedures for other indications or when contraindications exist (active local/systemic infection, inadequate bone stock, osteonecrosis >50%, skeletal immaturity, uncontrolled/unstable comorbidities, severe immunocompromise, Charcot joint, etc.); documentation must show failed conservative care or justify why non‑surgical management is inappropriate and meet imaging and procedure‑specific documentation requirements.