IEX: Submission of medical documentation for surgery of hip and knee

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

Providers requesting prior authorization for total joint replacement CPT^® codes 27445, 27447, 27130 and 27132 for UnitedHealthcare Individual Exchange plans members may need to submit additional medical documentation. This affects Individual Exchange plans¹ 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 Policy
• Surgery of the Knee — Commercial and Individual Exchange Medical Policy

Summary of changes

• Surgery of the hip: Medical notes documenting the following, when applicable:
  • Complete diagnostic interpretation of imaging findings including, at a minimum:
    1. Relevant clinical information
    2. Detailed report of imaging findings 
    3. Impression
    4. Specialty(ies) of the provider(s) who interpreted the images
       • 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.

• Surgery of the knee: Medical notes documenting the following, when applicable:
  • Complete diagnostic interpretation of imaging findings including, at a minimum:
    1. Relevant clinical information
    2. Detailed report of imaging findings, including at least the following:
       • 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