Total Joint Arthroplasty

Total knee and total hip arthroplasty are covered when patients have advanced joint disease with radiographic evidence (Kellgren–Lawrence ≥2 or equivalent), moderate-to-severe pain and functional loss documented with standardized scales, a trial of ≥3 months of conservative therapy (or documented rationale if not appropriate), and optimization of comorbidities where applicable. Revisions are covered when there is documented cause of primary failure and modifiable factors have been addressed. Procedures are contraindicated for active infection, neuropathic arthritis, skeletal immaturity, rapidly progressive neurologic disease, quadriplegia, or permanent muscle weakness without pain, and implants should comply with FDA device regulations.

"Primary total knee arthroplasty (TKA) is medically necessary for knee osteoarthritis with joint destruction."

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