Total Knee Arthroplasty

Total knee arthroplasty is considered medically necessary for patients with advanced knee joint disease demonstrated on imaging plus pain or functional disability, generally after unsuccessful conservative management or when conservative therapy is clearly inappropriate. Additional indications include fractures, avascular necrosis, malignancy in the distal femur/proximal tibia/adjacent tissues, failure of prior unicompartmental or osteotomy procedures, and specific causes for revision TKA (infection, loosening, fracture, bone loss, wear, malalignment, stiffness, or instability). Coverage is excluded for active infections, active systemic bacteremia, certain active local infections or wounds, rapidly progressive neurologic disease, and several relative contraindications unless explicit rationale is documented; the LCD is not intended to guide unicompartmental knee replacement decisions.

"Advanced knee joint disease demonstrated by imaging (radiograph; if radiography inadequate, MRI or CT) showing findings such as subchondral cysts, sclerosis, osteophytes, subluxation, joint space n..."