CMM-313: Hip Replacement/ Arthroplasty

Covered: medically necessary partial and total hip resurfacing, partial and total hip arthroplasty (including specified fracture indications), and total hip revision when indications are met; excluded/not medically necessary for active local/systemic infection, inadequate bone stock, uncontrolled/unstable comorbidities, morbid obesity (BMI ≥40), osteonecrosis >50%, skeletally immature patients, severe neuromuscular/vascular compromise, and simultaneous bilateral THR. Key requirements: age limits (resurfacing generally ≤64; some partial arthroplasty fracture indications ≥65), required radiographic findings (joint-space narrowing, Tonnis Grade 3 or <50% femoral-head osteonecrosis), documented chronic severe disabling pain (3 months for partial resurfacing; 6 months for total resurfacing/arthroplasty), failure of adequate nonsurgical management (typically ≥3 months), appropriate fracture morphology or prior-arthroplasty complications for revisions, and supporting imaging and clinical documentation.