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L.7.01.436
Total hip arthroplasty (THA), also called total hip replacement (THR), is performed by removing the affected hip joint and replacing it with an artificial joint, called a hip implant or prosthesis. THA is most commonly performed as a treatment for deterioration of the hip joint due to a variety of musculoskeletal conditions, such as osteoarthritis, osteonecrosis, or other types of inflammatory arthritis. The aims of hip arthroplasty are relief of pain and improvement in joint function.
Traditionally, an inpatient hospital stay was required for all joint replacement procedures. Three primary factors made inpatient hospitalization necessary: pain control, physical therapy, and the possible need for blood transfusion. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have strikingly reduced the hospital stay. Adjustments to anesthesia and other medications reduce pain more effectively while also minimizing side effects like nausea that could delay recovery.
Related medical policies -
Total Hip Arthroplasty (THA) is considered medically necessary when ALL of the following criteria are met:
A diagnosis of osteoarthritis (OA), osteonecrosis, or rheumatoid arthritis (RA), bone tumor involving the hip or acute femoral neck fracture,
Radiographic evidence of hip joint damage,
Significant persistent pain and functional limitations that interfere with activities of daily living, e.g., reduced walking distance, inability to work,
Optimal medical management has been tried and failed, including but not limited to:
Weight loss efforts
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Disease modifying antirheumatic drugs (DMARDs)
Cortisone injections
Physical therapy
Walking aids
Physical activity reduction
Revision THA of the previous failed hip prosthesis with a new prosthesis may be considered medically necessary in individuals with significant increase in pain/swelling and/or decrease in hip function, in the presence of any of the following:
Infection
Wear and loosening
Malalignment or malposition
Fractures
Instability
The Company requires care coordination for all hip arthroplasty Specialty Services, to determine 1) Whether medical necessity and medical policy guidelines have been met and 2) Most appropriate Place of Treatment.
Hospital Criteria
Hip arthroplasty (including revision arthroplasty) is considered medically necessary in the hospital setting in adults (18 and older) that meet the above medical necessity criteria AND one or more of the following additional clinical requirements:
American Society of Anesthesiologists (ASA) Physical Status classification of ASA PS 4 or more, or
Body Mass Index (BMI) 50 or more subject to physician discretion, or
Body Mass Index (BMI) 40 – 49 with an additional clinical criteria listed in policy, or
Pregnant, or
Known history of difficult airway/intubation, or
Known history or strong family history of malignant hyperthermia, psudocholinesterase deficiency or other anesthesia complication, or
Known history of recent myocardial infarction (less than 6 months), or
Pacemakers or Internal Automatic Defibrillators at physician discretion, or
Recent sepsis (less than 3 months), or
History of cirrhosis (MELD Score >8), or
Chronic Obstructive Pulmonary Disease (COPD) with FEV1<50%, or
End stage renal disease (on dialysis), or
Expected operative time > 120 minutes, or
Hemoglobin <12 or other anticipated need for blood transfusion or replacement clotting factor (i.e. bleeding disorder), or
Uncompensated chronic heart failure (NYHA class III or IV), or
Poorly controlled, resistant hypertension (3 or more drugs to control blood pressure), or
Recent history of cerebrovascular accident (<3 months), or
Increased risk for cardiac ischemia (drug eluting stent placed <1 year or angioplasty <90 days), or
Symptomatic cardiac arrhythmia despite medication, or
Significant valvular heart disease, or
Poorly controlled asthma (FEV1 <80% despite treatment), or
Moderate to severe obstructive sleep apnea defined as Apnea/Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) >= 15 events/hour not compliant with CPAP or compliant with CPAP but have non-optimized comorbid conditions, or
Have a presumptive diagnosis of obstructive sleep apnea determined by STOP-Bang screening questionnaire and have non-optimized comorbid conditions, or
Have known moderate to severe obstructive sleep apnea or presumptive diagnosis of obstructive sleep apnea and post-operative pain cannot be managed predominantly with non-opioid analgesics, or
Substance use disorder (opioids, alcohol, street drugs), or
Procedural considerations subject to Company approval.
Benefits are only provided for hospital hip arthroplasty Specialty Services when medical necessity and medical policy guidelines including hospital setting criteria have been met and care coordinated by the Company. BCBSMS will provide coverage for all other hip arthroplasty Specialty Services that meet medical necessity and medical policy guidelines if rendered by a Blue Specialty Network Provider in a setting coordinated and contracted with the Company.
This Total Hip Arthroplasty (THA) – West Central and North East Region Medical Policy is applicable to Network Providers in the West Central and North East Regions of Mississippi only. The West Central and North East Regions include counties Alcorn, Attala, Benton, Bolivar, Calhoun, Carroll, Chickasaw, Choctaw, Claiborne, Clay, Copiah, Grenada, Hinds, Holmes, Humphreys, Issaquena, Itawamba, Leake, Lee, Leflore, Lowndes, Madison, Monroe, Montgomery, Oktibbeha, Pontotoc, Prentiss, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Tippah, Tishomingo, Union, Warren, Washington, Webster, Yalobusha, and Yazoo.
State Health Plan (State and School Employees): All Inpatient Hospital admissions for total hip arthroplasty must be certified as medically necessary by the State Health Plan’s Utilization Review Vendor.
BlueCard Claims: This Medical Policy does not apply to Inpatient Hospital admissions for total hip arthroplasty performed and submitted under the BlueCard® Program for Members of other Plans.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
08/30/2019: New policy added.
09/13/2019: Made correction to medical policy number.
10/01/2020: Policy title changed from "Total Hip Arthroplasty (THA) - West Central Region" to "Total Hip Arthroplasty (THA) - West Central and North East Region." Policy Exceptions updated to list additional counties.
02/22/2022: Policy statement updated to change “Inpatient” criteria to “Hospital” criteria effective 01/01/2022.
02/06/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
04/10/2024: Policy reviewed; no changes.
07/01/2024: Policy updated to state that care coordination is required for Specialty Services.
03/27/2025: Policy reviewed; no changes.
American Academy of Orthopaedic Surgeons (AAOS). Total Hip Replacement. http://orthoinfo.aaos.org/topic.cfm?topic=A00377
Journal of Clinical Anesthesia. The association of body mass index with same-day admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy
Medical Policy Advisory Committee
Premera Blue Cross Medical Policy 7.01.551
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Medically Necessary Codes
Code Number | Description |
CPT-4 | |
27130 | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft [Hip resurfacing for arthroplasty] |
27132 | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft |
27134 | Hip Revision of total hip arthroplasty; both components, with or without autograft or allograft |
27137 | Hip Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft |
27138 | Hip Revision of total hip arthroplasty; femoral component only, with or without allograft |
HCPCS | |
ICD-10 Procedure | |
0SP908Z | Removal of spacer from right hip joint, open approach |
0SP909Z | Removal of liner from right hip joint, open approach |
0SP90BZ | Removal of resurfacing device from right hip joint, open approach |
0SP90JZ | Removal of synthetic substitute from right hip joint, open approach |
0SPB08Z | Removal of spacer from left hip joint, open approach |
0SPB09Z | Removal of liner from left hip joint, open approach |
0SPB0BZ | Removal of resurfacing device from left hip joint, open approach |
0SPB0JZ | Removal of synthetic substitute from left hip joint, open approach |
0SR9019 | Replacement of right hip joint with metal synthetic substitute, cemented, open approach |
0SR901A | Replacement of right hip joint with metal synthetic substitute, uncemented, open approach |
0SR901Z | Replacement of right hip joint with metal synthetic substitute, open approach |
0SR9029 | Replacement of right hip joint with metal on polyethylene synthetic substitute, cemented, open approach |
0SR902A | Replacement of right hip joint with metal on polyethylene synthetic substitute, uncemented, open approach |
0SR902Z | Replacement of right hip joint with metal on polyethylene synthetic substitute, open approach |
0SR9039 | Replacement of right hip joint with ceramic synthetic substitute, cemented, open approach |
0SR903A | Replacement of right hip joint with ceramic synthetic substitute, uncemented, open approach |
0SR903Z | Replacement of right hip joint with ceramic synthetic substitute, open approach |
0SR9049 | Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach |
0SR904A | Replacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach |
0SR904Z | Replacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach |
0SR9069 | Replacement of right hip joint with oxidized zirconium on polyethylene synthetic substitute, cemented, open approach |
0SR906A | Replacement of right hip joint with oxidized zirconium on polyethylene synthetic substitute, uncemented, open approach |
0SR906Z | Replacement of right hip joint with oxidized zirconium on polyethylene synthetic substitute, open approach |
0SR907Z | Replacement of right hip joint with autologous tissue substitute, open approach |
0SR90EZ | Replacement of right hip joint with articulating spacer, open approach |
0SR90J9 | Replacement of right hip joint with synthetic substitute, cemented, open approach |
0SR90JA | Replacement of right hip joint with synthetic substitute, uncemented, open approach |
0SR90JZ | Replacement of right hip joint with synthetic substitute, open approach |
0SR90KZ | Replacement of right hip joint with nonautologous tissue substitute, open approach |
0SRA009 | Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach |
0SRA00A | Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach |
0SRA00Z | Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, open approach |
0SRA019 | Replacement of right hip joint, acetabular surface with metal synthetic substitute, cemented, open approach |
0SRA01A | Replacement of right hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach |
0SRA01Z | Replacement of right hip joint, acetabular surface with metal synthetic substitute, open approach |
0SRA039 | Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach |
0SRA03A | Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach |
0SRA03Z | Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, open approach |
0SRA0J9 | Replacement of right hip joint, acetabular surface with synthetic substitute, cemented, open approach |
0SRA0JA | Replacement of right hip joint, acetabular surface with synthetic substitute, uncemented, open approach |
0SRA0JZ | Replacement of right hip joint, acetabular surface with synthetic substitute, open approach |
0SRB019 | Replacement of left hip joint with metal synthetic substitute, cemented, open approach |
0SRB01A | Replacement of left hip joint with metal synthetic substitute, uncemented, open approach |
0SRB01Z | Replacement of left hip joint with metal synthetic substitute, open approach |
0SRB029 | Replacement of left hip joint with metal on polyethylene synthetic substitute, cemented, open approach |
0SRB02A | Replacement of left hip joint with metal on polyethylene synthetic substitute, uncemented, open approach |
0SRB02Z | Replacement of left hip joint with metal on polyethylene synthetic substitute, open approach |
0SRB039 | Replacement of left hip joint with ceramic synthetic substitute, cemented, open approach |
0SRB03A | Replacement of left hip joint with ceramic synthetic substitute, uncemented, open approach |
0SRB03Z | Replacement of left hip joint with ceramic synthetic substitute, open approach |
0SRB049 | Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach |
0SRB04A | Replacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach |
0SRB04Z | Replacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach |
0SRB069 | Replacement of left hip joint with oxidized zirconium on polyethylene synthetic substitute, cemented, open approach |
0SRB06A | Replacement of left hip joint with oxidized zirconium on polyethylene synthetic substitute, uncemented, open approach |
0SRB06Z | Replacement of left hip joint with oxidized zirconium on polyethylene synthetic substitute, open approach |
0SRB07Z | Replacement of left hip joint with autologous tissue substitute, open approach |
0SRB0EZ | Replacement of left hip joint with articulating spacer, open approach |
0SRB0J9 | Replacement of left hip joint with synthetic substitute, cemented, open approach |
0SRB0JA | Replacement of left hip joint with synthetic substitute, uncemented, open approach |
0SRB0JZ | Replacement of left hip joint with synthetic substitute, open approach |
0SRB0KZ | Replacement of left hip joint with nonautologous tissue substitute, open approach |
0SRE009 | Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach |
0SRE00A | Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach |
0SRE00Z | Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, open approach |
0SRE019 | Replacement of left hip joint, acetabular surface with metal synthetic substitute, cemented, open approach |
0SRE01A | Replacement of left hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach |
0SRE01Z | Replacement of left hip joint, acetabular surface with metal synthetic substitute, open approach |
0SRE039 | Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach |
0SRE03A | Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach |
0SRE03Z | Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, open approach |
0SRE0J9 | Replacement of left hip joint, acetabular surface with synthetic substitute, cemented, open approach |
0SRE0JA | Replacement of left hip joint, acetabular surface with synthetic substitute, uncemented, open approach |
0SRE0JZ | Replacement of left hip joint, acetabular surface with synthetic substitute, open approach |
0SRR019 | Replacement of right hip joint, femoral surface with metal synthetic substitute, cemented, open approach |
0SRR01A | Replacement of right hip joint, femoral surface with metal synthetic substitute, uncemented, open approach |
0SRR01Z | Replacement of right hip joint, femoral surface with metal synthetic substitute, open approach |
0SRR039 | Replacement of right hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach |
0SRR03A | Replacement of right hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach |
0SRR03Z | Replacement of right hip joint, femoral surface with ceramic synthetic substitute, open approach |
0SRR0J9 | Replacement of right hip joint, femoral surface with synthetic substitute, cemented, open approach |
0SRR0JA | Replacement of right hip joint, femoral surface with synthetic substitute, uncemented, open approach |
0SRS019 | Replacement of left hip joint, femoral surface with metal synthetic substitute, cemented, open approach |
0SRS01A | Replacement of left hip joint, femoral surface with metal synthetic substitute, uncemented, open approach |
0SRS01Z | Replacement of left hip joint, femoral surface with metal synthetic substitute, open approach |
0SRS039 | Replacement of left hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach |
0SRS03A | Replacement of left hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach |
0SRS03Z | Replacement of left hip joint, femoral surface with ceramic synthetic substitute, open approach |
0SRS0J9 | Replacement of left hip joint, femoral surface with synthetic substitute, cemented, open approach |
0SRS0JZ | Replacement of left hip joint, femoral surface with synthetic substitute, open approach |
0SU909Z | Supplement right hip joint with liner, open approach |
0SUA09Z | Supplement right hip joint, acetabular surface with liner, open approach |
0SUB09Z | Supplement left hip joint with liner, open approach |
0SUE09Z | Supplement left hip joint, acetabular surface with liner, open approach |
0SUR09Z | Supplement right hip joint, femoral surface with liner, open approach |
0SUS09Z | Supplement left hip joint, femoral surface with liner, open approach |
0SUV09Z | Supplement right knee joint, tibial surface with liner, open approach |
0SW90JZ | Revision of synthetic substitute in right hip joint, open approach |
0SW93JZ | Revision of synthetic substitute in right hip joint, percutaneous approach |
0SW94JZ | Revision of synthetic substitute in right hip joint, percutaneous endoscopic approach |
0SWB0JZ | Revision of synthetic substitute in left hip joint, open approach |
0SWB3JZ | Revision of synthetic substitute in left hip joint, percutaneous approach |
0SWB4JZ | Revision of synthetic substitute in left hip joint, percutaneous endoscopic approach |
ICD-10 Diagnosis |
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