CMM-311: Knee Replacement/Arthroplasty

This policy covers partial (unicompartmental), total, revision knee arthroplasty and isolated polyethylene liner exchange when specific clinical indications are met, and excludes procedures for active infection, uncorrectable severe deformity/instability, unoptimized significant comorbidities, or experimental/unsupported devices or techniques. Key requirements include function‑limiting pain ≥3 months (≥6 months if BMI>40), loss of function, appropriate radiographic/arthroscopic severity (e.g., Kellgren‑Lawrence Grade IV or Outerbridge Grade IV) or AVN, intact ligaments and >90° ROM for unicompartmental cases, documented failure of provider‑directed non‑surgical management, and supporting documentation (imaging, clinical notes, optimization of comorbidities); revisions and IPE require procedure‑specific indications such as infection, aseptic loosening, fracture, implant failure, progressive osteolysis, stiffness or instability as detailed in the policy.

"Isolated polyethylene liner exchange (IPE) is considered medically necessary when ANY of the following criteria have been met:"