Total Joint Arthroplasty

Total hip and knee arthroplasty (including revision procedures) are covered when specific clinical indications are met, such as advanced joint disease documented by X-ray or MRI with pain/functional limitation and a failed trial of non-surgical management of at least 3 months, or specific causes like fracture, malignancy, implant loosening, infection, or mechanical failure. Coverage is denied when none of the indications apply or when contraindications are present (active joint or systemic infection, active skin infection/open wound at the surgical site, or rapidly progressive neurological disease except with a displaced femoral neck fracture); documentation requirements and criteria must be met for each joint when bilateral procedures are performed.

"Total knee arthroplasty (TKA) is reasonable and necessary for individuals with advanced knee joint disease evidenced by conventional radiography or MRI, with pain or functional disability attributa..."