Major Joint Replacement (Hip and Knee)

Medically necessary total hip and total knee arthroplasty are covered for advanced joint disease, fractures, avascular necrosis, malignancy, failed prior procedures, and specific prosthesis failures when supported by imaging, symptoms (pain or functional disability), and documented unsuccessful conservative therapy (usually ≥3 months). Revision procedures are covered for pain, instability, infection, implant failure, periprosthetic fracture, substantial bone loss, and other prosthesis-related complications. Coverage is excluded for active joint or systemic infection, active skin infection at the surgical site, neuropathic arthritis, and rapidly progressive neurological disease, and implants must be FDA-classified devices with appropriately qualified providers documented.

"Total knee arthroplasty (TKA) is indicated for failure of a previous knee osteotomy."

Sign up to see full coverage criteria, indications, and limitations.