CMM-311: Knee Replacement/Arthroplasty

Covers partial (medial/lateral/patellofemoral), total, revision knee arthroplasty and isolated polyethylene liner exchange when specific criteria are met — generally function‑limiting pain for ≥3 months (≥6 months if BMI >40), loss of knee function, radiographic/arthroscopic evidence of severe arthritis/AVN (Kellgren‑Lawrence IV or Outerbridge IV/exposed subchondral bone), failure of provider‑directed non‑surgical care (or documented reasons it’s inappropriate), plus procedure‑specific requirements (e.g., intact/stable ligaments and >90° ROM for partials; listed revision indications or well‑fixed components for liner exchange). Excluded are active local/systemic infection, inflammatory arthropathy, unoptimized medical/behavioral comorbidities, severe deformity or instability beyond specified thresholds (e.g., partial: flexion contracture >15°, varus >15°/valgus >20°; total: fixed deformity >30°), osseous abnormalities, and other stated limitations, and full documentation of symptoms, imaging (grading), prior conservative care and optimization is required.