CMM-313: Hip Replacement/ Arthroplasty

This policy covers hip resurfacing (partial/total), partial and total hip arthroplasty, revisions, isolated head/liner exchange and salvage procedures for specified indications (e.g., certain fractures, Tönnis grade 3 osteoarthritis, early osteonecrosis, component failure/instability or infection, eccentric polyethylene wear). Key requirements include documented function‑limiting hip pain for ≥3 months (≥6 months if BMI>40), failure of provider‑directed non‑surgical management, qualifying radiographic findings, age ≤64 for resurfacing, and exclusions such as active infection, inadequate bone stock, severe comorbidities or immunocompromise, skeletal immaturity, Charcot joint, and osteonecrosis >50% for resurfacing.

"Age restriction for resurfacing procedures: Individual must be age 64 years or younger for partial and total hip resurfacing arthroplasty."

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