CMM-311: Knee Replacement/Arthroplasty

Partial (unicompartmental), total, and revision knee arthroplasty are covered when there is chronic (≥6 months) severe, disabling pain with functional loss and failure of non‑surgical care, objective radiographic/arthroscopic evidence of end‑stage compartmental arthritis (Kellgren‑Lawrence IV or Modified Outerbridge IV), required ROM (partial >90°, total >50°), and for unicompartmental procedures intact/stable ligaments (especially ACL); revisions require prior arthroplasty plus component failure, infection, fracture, aseptic loosening, instability or unexplained pain >6 months. Excluded/not medically necessary conditions include active local or systemic infection, severe neuromuscular/vascular compromise or osteoporosis, specified fixed deformities (flexion contracture >15°, varus >15° or valgus >20°), prior high tibial osteotomy or severe patellofemoral disease for unicompartmental cases, and bicompartmental/bi‑unicompartmental arthroplasty, UniSpacer and similar devices are considered experimental/investigational.