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L.7.01.416
Total knee arthroplasty (TKA), also called total knee replacement (TKR), is most commonly performed for knee joint failure caused by osteoarthritis (OA) and other types of inflammatory arthritis. The aims of TKA are relief of pain and improvement in function by removing damaged cartilage at interfacing surfaces of the femur, tibia and/or patella and then resurfacing the damaged interface areas with artificial implants.
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 Knee Arthroplasty (TKA) is considered medically necessary when ALL of the following criteria are met:
1. A diagnosis of osteoarthritis (OA), osteonecrosis, or rheumatoid arthritis (RA), AND
2. Radiographic evidence of joint damage, AND
3. End-stage disease with exposed bone in ≥ 1 knee compartment, AND
4. Significant persistent pain and functional limitations that interfere with activities of daily living, e.g., reduced walking distance, inability to work, AND
5. Optimal medical management has been tried and failed, including but not limited to:
Weight loss efforts
Nonsteroidal anti-inflammatory medications (NSAIDs)
Disease modifying antirheumatic drugs (DMARDs)
Cortisone injections
Lubricating injections
Physical therapy
External support (e.g., brace)
Revision TKA or replacement of the previous failed knee prosthesis with a new prosthesis may be considered medically necessary in individuals with significant increase in pain/swelling and/or decrease in knee function, in the presence of any of the following:
Infection
Wear and loosening
Malalignment or malposition
Fractures
Instability
Ambulatory TKA or revision TKA is considered medically necessary in the ambulatory setting in adults (18 and older) that meet the above medical necessity criteria AND the following additional clinical requirements:
American Society of Anesthesiologists (ASA) Physical Status classification of ASA PS 3 or less, AND
Body Mass Index (BMI) 50 or less, AND
Proactive treatment for possible Methicillin-Susceptible Staphylococcus Aureus (MSSA)/Methicillin-Resistant Staphylococcus Aureus (MRSA) preoperatively, AND
Absence of ALL of the following contraindications: 1. Pregnant2. Known history of difficult airway/intubation3. Fasting blood glucose level of 275 or greater on date of procedure4. Known history or strong family history of malignant hyperthermia5. Known history of psuedocholinesterase deficiency6. Known history of recent myocardial infarction (less than 6 months) 7. Pacemakers or Internal Automatic Defibrillators8. Recent sepsis9. History of cirrhosis or Chronic Obstructive Pulmonary Disease (COPD)10. On dialysis11. Expected operative time > 120 minutes12. Hemoglobin <12
The Company requires care coordination for ambulatory TKA or revision TKA Specialty Services, to determine 1) Whether medical necessity and medical policy guidelines have been met and 2) Whether these Specialty Services can be performed by a Blue Specialty Network Provider.
Benefits are only provided when these ambulatory TKA or revision TKA Specialty Services are performed by a Blue Specialty Network Provider in a setting coordinated and contracted with the Company.
State Health Plan (State and School Employees): The Total Knee Arthroplasty (TKA) Medical Policy guidelines apply to State Health Plan Members effective 09/01/2017.
This Medical Policy is not applicable to Network Providers in the West Central and North East Regions of Mississippi. Refer to the Knee Arthroplasty – West Central and North East Region Medical Policy for coverage and medical necessity guidelines. The West Central Region includes counties Attala, Bolivar, Carroll, Claiborne, Copiah, Grenada, Hinds, Holmes, Humphreys, Issaquena, Leake, Leflore, Madison, Montgomery, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Warren, Washington, Yalobusha, and Yazoo. The North East Region includes counties Alcorn, Benton, Calhoun, Chickasaw, Choctaw, Clay, Itawamba, Lee, Lowndes, Monroe, Oktibbeha, Pontotoc, Prentiss, Tippah, Tishomingo, Union, and Webster.
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.
02/04/2016: New policy added.
06/01/2016: Policy number L.7.01.416 added.
09/01/2017: Policy statement revised to change the medically necessary American Society of Anesthesiologists (ASA) Physical Status classification for outpatient TKA or revision TKA from "ASA PS 1 or ASA PS 2 only" to "ASA PS 3 or less." Also, Body Mass Index (BMI) changed from "35 or less" to "40 or less." Policy Exceptions section updated to note that the Medical Policy guidelines apply to State Health Plan Members effective 09/01/2017.
05/18/2018: Medical policy links updated in policy description.
01/01/2019: Revised language from "outpatient" to "ambulatory."
08/30/2019: Policy statement updated to change the Body Mass Index (BMI) requirement from "40 or less" to "50 or less." Added a link to the related Knee Arthroplasty - West Central Region Medical Policy. Policy Exceptions updated to state that this Medical Policy is not applicable to Network Providers in the West Central Region of Mississippi. Refer to the Knee Arthroplasty – West Central Region Medical Policy for coverage and medical necessity guidelines. The West Central Region includes counties Attala, Bolivar, Carroll, Claiborne, Copiah, Grenada, Hinds, Holmes, Humphreys, Issaquena, Leake, Leflore, Madison, Montgomery, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Warren, Washington, Yalobusha, and Yazoo. Sources updated.
10/01/2020: Policy Exceptions updated to add the North East Region of Mississippi, which includes counties Alcorn, Benton, Calhoun, Chickasaw, Choctaw, Clay, Itawamba, Lee, Lowndes, Monroe, Oktibbeha, Pontotoc, Prentiss, Tippah, Tishomingo, Union, and Webster.
11/08/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Link for surgical options for knee arthritis updated in Sources section.
12/07/2023: Policy reviewed; no changes.
07/01/2024: Policy updated to state that care coordination is required for Specialty Services.
03/11/2025: Policy reviewed; no changes.
American Academy of Orthopedic Surgeons. Total Knee Replacement. http://orthoinfo.aaos.org/topic.cfm?topic=A00389
American Association of Hip and Knee Surgeons (AAHKS). Surgical Options for Knee Arthritis. https://hipknee.aahks.org/surgical-options-for-knee-arthritis/
American Association of Hip and Knee Surgeons (AAHKS). Total Knee Replacement. http://www.aahks.org/care-for-hips-and-knees/do-i-need-a-joint-replacement/total-knee-replacement/
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
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 | |
27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) |
27486 | Revision of total knee arthroplasty, with or without allograft; 1 component |
27487 | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component |
HCPCS | |
ICD-10 Procedure | |
ICD-10 Diagnosis |
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.