CMM-313: Hip Replacement/ Arthroplasty

Covers hip resurfacing, partial and total hip arthroplasty, revisions, isolated head/liner exchange and salvage procedures only when specific criteria are met (function‑limiting short‑distance pain ≥3 months — ≥6 months if BMI >40 — plus loss of function, required radiographic findings such as joint‑space narrowing or Tönnis Grade 3, osteonecrosis <50% and age ≤64 for resurfacing, or fracture/collapse indications). Excludes procedures when listed non‑indications are present (e.g., disease of both femoral head and acetabulum for resurfacing, osteonecrosis >50%, skeletal immaturity, active infection, inadequate bone stock, uncontrolled comorbidities, severe immunocompromise), and requires detailed medical-record documentation of symptoms, failed provider‑directed non‑surgical management, imaging, extent of disease, implant status and risk/benefit for comorbid patients.

"Partial hip resurfacing arthroplasty is considered not medically necessary for ANY other indication, condition, or when ANY of the following are present: Active local or systemic infection."