IFP: Submission of medical record documentation for Surgery of the Hip and Knee

Applies to CPT codes 27445, 27447, 27130 and 27132 for the indication of osteoarthritis

Providers requesting prior authorization for CPT® Total Joint Replacement codes 27445, 27447, 27130 and 27132 for members of UnitedHealthcare Individual Exchange plans, also referred to as UnitedHealthcare Individual & Family ACA Marketplace plans, may need to submit additional medical documentation. This affects Individual Exchange plans nationally. No new codes are being added to the prior authorization list.

Prior authorization requests for these codes will be reviewed against the following policies:

• Surgery of the Hip — Commercial and Individual Exchange Medical Policyopen_in_new
• Surgery of the Knee — Commercial and Individual Exchange Medical Policyopen_in_new
• Surgery of the Hip – Rocky Mountain Health Plans Medical Policyopen_in_new
• Surgery of the Knee – Rocky Mountain Health Plans Medical Policyopen_in_new

Summary of changes

• Surgery of the hip: Medical notes documenting the following, when applicable:
  • Complete diagnostic imaging report(s) that are separate and distinct from the professional component of an evaluation and management (E/M) office visit
  • Upon request, we may require the specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal images
• Surgery of the knee: Medical notes documenting the following, when applicable:
  • Complete diagnostic imaging report(s) that are separate and distinct from the professional component of an evaluation and management office visit.
    • Documented closure of skeletal plates (age less than 18 years)
    • Presence or absence of focal full-thickness articular cartilage defect
    • Size and location of focal cartilage defect
    • Outerbridge grade
    • Joint space and alignment
    • Ligament tear location and grade
  • In addition, upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal images

Conservative care requirements remain unchanged

The following treatments and their associated timing and duration should be easily identifiable in the clinical documentation.

Treatment within the last year must include:

• NSAIDs or acetaminophen ≥ 3 weeks*
• PT or home exercise ≥ 12 weeks
• Activity modification ≥ 12 weeks