Lower Extremity Major Joint Replacement (Hip and Knee)

Medicare considers total hip and total knee arthroplasty medically reasonable and necessary when at least three of the LCD-specified indications for the hip or knee are met, including radiographic/MRI evidence of advanced joint disease, documented failure of conservative therapy (usually ≥3 months), pain with functional disability, distinct structural abnormalities, or failed prior arthroplasty requiring revision. Procedures are denied if indications are unmet or contraindications exist (active joint/systemic infection, active skin infection at the surgical site, progressive neurological disease), and services must be performed by appropriately trained and documented providers with required pre-procedure imaging and medical-record documentation of conservative management and revision rationale.

"Total knee arthroplasty (TKA) is considered medically reasonable and necessary only when at least three of the knee-specific indications listed in this LCD are met."