Aetna Hip Arthroplasty (Total Hip Implants) coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Primary Total Hip Arthroplasty (THA): FDA-approved metal-on-metal, metal-on-plastic, ceramic-on-plastic, or ceramic-on-ceramic THA prosthesis is medically necessary for adult members when ALL of the following are met (advanced joint disease criteria, conservative therapy requirement, and absence of absolute contraindications).
• Primary THA - Advanced joint disease (must meet ALL of): (a) Pain and functional disability interfering with activities of daily living (ADLs) from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the hip joint; AND (b) Limited range of motion (ROM), antalgic gait, and pain in hip joint with passive ROM on physical examination; AND (c) Radiographic evidence of ONE of: avascular necrosis (osteonecrosis) with stage II or III disease OR moderate/severe osteoarthritis or rheumatoid arthritis of the hip joint (Tonnis grade 2 or 3).
• Primary THA - Conservative therapy requirement: History of unsuccessful non-surgical medical management documented in the medical record (at least 12 weeks; at least 24 weeks for persons with a relative contraindication), with at least half of the necessary conservative therapy consisting of formal in-person physical therapy with a licensed physical therapist (not home or virtual) in the past year, confirmed by actual PT notes or member claims history. WAIVED/EXCEPTION: if conservative therapy is not appropriate (e.g., progressive flexion contracture, avascular necrosis with collapse of the femoral head, or bone-on-bone arthritis in the weight-bearing portion of the joint), the medical record must clearly document why such approach is not reasonable.
• Primary THA - Conservative therapy must include ALL of (unless contraindicated): (a) anti-inflammatory medications or analgesics; AND (b) flexibility and muscle strengthening exercises; AND (c) activity modification; AND (d) supervised in-person physical therapy with a licensed physical therapist (ADLs diminished despite completing a plan of care), confirmed by PT notes or claims history; AND (e) assistive device use (REQUIRED for persons with relative contraindications, optional for others); AND (f) therapeutic injections into the hip (REQUIRED for persons with relative contraindications, optional for others).
• Primary THA - Relative contraindications (require exhaustion of ALL non-surgical options and trigger the 24-week conservative therapy duration plus required assistive device and therapeutic injection use): morbid obesity (BMI greater than 40); OR age less than 50 years.
• Primary THA - Alternative indications (THA medically necessary if ANY ONE of): fracture of the femoral neck by imaging; OR malunion of acetabular, femoral head, or proximal femur fracture with pain interfering with ADLs; OR nonunion by imaging or failure of previous hip fracture surgery; OR malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur by imaging.
• Primary THA - Diabetic members: hemoglobin A1c (HbA1c) should be less than 8 percent within 3 months prior to hip arthroplasty.
• Primary THA - Comorbidity consideration: for persons with significant conditions or co-morbidities, the risk/benefit of THA should be appropriately addressed in the medical record.
• Revision or replacement of THA or hip resurfacing arthroplasty is medically necessary when accompanied by pain and functional disability (interference with ADLs) AND member has ONE OR MORE of the following indications AND does NOT have the listed revision contraindications.
• Revision/replacement - Indications (ONE OR MORE of): aseptic loosening of one or more prosthetic components confirmed by imaging; OR fracture or mechanical failure of one or more components of the prosthesis confirmed by imaging; OR confirmed periprosthetic infection confirmed by gram stain and culture (a single-stage revision is medically necessary, UNLESS there has been a prior infection in the same joint, in which case a multi-stage revision may be considered medically necessary); OR displaced periprosthetic fracture confirmed by imaging; OR progressive or substantial periprosthetic bone loss confirmed by imaging; OR bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; OR recurrent (2 or more) dislocations confirmed by imaging not responsive to a reasonable course of conservative management, or irreducible dislocation confirmed by imaging; OR clinically significant leg length discrepancy.
• Custom-made implants: FDA-approved custom-made implant for Paprosky type III acetabular defects where the feature of the defect cannot be handled with standard implants, AND the member meets the criteria for revision total hip arthroplasty listed above.
• Iliopsoas tenotomy (or lengthening) by any surgical approach for iliopsoas tendinopathy following total hip arthroplasty, with failure of at least 6 weeks of formal in-person physical therapy in the past year AND at least 1 therapeutic injection (steroid with or without local anesthetic) with significant but temporary benefit in the past 6 months.
• Surgical approach: minimal incision or minimally invasive THA is an acceptable alternative to conventional THA.
• Prophylactic use of tranexamic acid in total hip arthroplasty to decrease blood loss is medically necessary.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 27130·PA verdict·Rate
• 27132·PA verdict·Rate
• 27134·PA verdict·Rate
• 27137·PA verdict·Rate
• 27138·PA verdict·Rate

Documentation required

• Medical record clearly addressing the history and results of conservative (non-surgical) therapy, including duration (at least 12 weeks; at least 24 weeks for persons with a relative contraindication).
• Formal in-person physical therapy confirmed either by the actual PT notes or by documentation in the member claims history.
• Where conservative therapy is not appropriate, medical record documentation clearly explaining why such an approach is not reasonable.
• Physical examination findings documenting limited range of motion, antalgic gait, and pain in the hip joint with passive ROM.
• Radiographic evidence documenting avascular necrosis stage II or III, or moderate/severe osteoarthritis or rheumatoid arthritis (Tonnis grade 2 or 3).
• For diabetic members: HbA1c less than 8 percent within 3 months prior to hip arthroplasty.
• For persons with significant conditions or comorbidities: risk/benefit of THA appropriately addressed in the medical record.
• For revision/replacement: imaging confirmation of the specific indication, and medical record addressing the revision contraindications.
• For iliopsoas tenotomy/lengthening: documentation of failure of at least 6 weeks of formal in-person physical therapy in the past year and at least 1 therapeutic injection with significant but temporary benefit in the past 6 months.

Frequently asked questions

When does Aetna cover Hip Arthroplasty (Total Hip Implants) (CPT 27130), and what gets it denied?

Aetna covers total hip arthroplasty (and revision/replacement of a hip or resurfacing implant) for adults with advanced, disabling hip joint disease shown on exam and imaging, with the key gate being documented failure of at least 12 weeks of conservative therapy (24 weeks, with required injections and assistive devices, for those under 50 or with BMI over 40), unless surgery is driven by fracture, malunion/nonunion, malignancy, or other listed exceptions. Coverage is denied when absolute contraindications exist (e.g., active infection, implant-component allergy, recent joint steroid injection, skeletal immaturity) and several adjuncts are experimental/investigational, including computer-assisted/robotic navigation, AR/VR assistance, custom implants (outside Paprosky type III defects), the alpha-defensin/Synovasure test, and revision for metallosis alone. The bulletin states precertification may be required for select procedures (check the CPT code search tool), so PA status is not definitively stated. Coverage criteria include: Primary Total Hip Arthroplasty (THA): FDA-approved metal-on-metal, metal-on-plastic, ceramic-on-plastic, or ceramic-on-ceramic THA prosthesis is medically necessary for adult members when ALL of the following are met (advanced joint disease criteria, conservative therapy requirement, and absence of absolute contraindications).; Primary THA - Advanced joint disease (must meet ALL of): (a) Pain and functional disability interfering with activities of daily living (ADLs) from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the hip joint; AND (b) Limited range of motion (ROM), antalgic gait, and pain in hip joint with passive ROM on physical examination; AND (c) Radiographic evidence of ONE of: avascular necrosis (osteonecrosis) with stage II or III disease OR moderate/severe osteoarthritis or rheumatoid arthritis of the hip joint (Tonnis grade 2 or 3).; Primary THA - Conservative therapy requirement: History of unsuccessful non-surgical medical management documented in the medical record (at least 12 weeks; at least 24 weeks for persons with a relative contraindication), with at least half of the necessary conservative therapy consisting of formal in-person physical therapy with a licensed physical therapist (not home or virtual) in the past year, confirmed by actual PT notes or member claims history. WAIVED/EXCEPTION: if conservative therapy is not appropriate (e.g., progressive flexion contracture, avascular necrosis with collapse of the femoral head, or bone-on-bone arthritis in the weight-bearing portion of the joint), the medical record must clearly document why such approach is not reasonable.; Primary THA - Conservative therapy must include ALL of (unless contraindicated): (a) anti-inflammatory medications or analgesics; AND (b) flexibility and muscle strengthening exercises; AND (c) activity modification; AND (d) supervised in-person physical therapy with a licensed physical therapist (ADLs diminished despite completing a plan of care), confirmed by PT notes or claims history; AND (e) assistive device use (REQUIRED for persons with relative contraindications, optional for others); AND (f) therapeutic injections into the hip (REQUIRED for persons with relative contraindications, optional for others).; Primary THA - Relative contraindications (require exhaustion of ALL non-surgical options and trigger the 24-week conservative therapy duration plus required assistive device and therapeutic injection use): morbid obesity (BMI greater than 40); OR age less than 50 years.; Primary THA - Alternative indications (THA medically necessary if ANY ONE of): fracture of the femoral neck by imaging; OR malunion of acetabular, femoral head, or proximal femur fracture with pain interfering with ADLs; OR nonunion by imaging or failure of previous hip fracture surgery; OR malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur by imaging.; Primary THA - Diabetic members: hemoglobin A1c (HbA1c) should be less than 8 percent within 3 months prior to hip arthroplasty.; Primary THA - Comorbidity consideration: for persons with significant conditions or co-morbidities, the risk/benefit of THA should be appropriately addressed in the medical record.; Revision or replacement of THA or hip resurfacing arthroplasty is medically necessary when accompanied by pain and functional disability (interference with ADLs) AND member has ONE OR MORE of the following indications AND does NOT have the listed revision contraindications.; Revision/replacement - Indications (ONE OR MORE of): aseptic loosening of one or more prosthetic components confirmed by imaging; OR fracture or mechanical failure of one or more components of the prosthesis confirmed by imaging; OR confirmed periprosthetic infection confirmed by gram stain and culture (a single-stage revision is medically necessary, UNLESS there has been a prior infection in the same joint, in which case a multi-stage revision may be considered medically necessary); OR displaced periprosthetic fracture confirmed by imaging; OR progressive or substantial periprosthetic bone loss confirmed by imaging; OR bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; OR recurrent (2 or more) dislocations confirmed by imaging not responsive to a reasonable course of conservative management, or irreducible dislocation confirmed by imaging; OR clinically significant leg length discrepancy.; Custom-made implants: FDA-approved custom-made implant for Paprosky type III acetabular defects where the feature of the defect cannot be handled with standard implants, AND the member meets the criteria for revision total hip arthroplasty listed above.; Iliopsoas tenotomy (or lengthening) by any surgical approach for iliopsoas tendinopathy following total hip arthroplasty, with failure of at least 6 weeks of formal in-person physical therapy in the past year AND at least 1 therapeutic injection (steroid with or without local anesthetic) with significant but temporary benefit in the past 6 months.; Surgical approach: minimal incision or minimally invasive THA is an acceptable alternative to conventional THA.; Prophylactic use of tranexamic acid in total hip arthroplasty to decrease blood loss is medically necessary.. Applies to 5 codes: 27130, 27132, 27134, 27137, 27138. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Note: Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Medical record clearly addressing the history and results of conservative (non-surgical) therapy, including duration (at least 12 weeks; at least 24 weeks for persons with a relative contraindication).; Formal in-person physical therapy confirmed either by the actual PT notes or by documentation in the member claims history.; Where conservative therapy is not appropriate, medical record documentation clearly explaining why such an approach is not reasonable.; Physical examination findings documenting limited range of motion, antalgic gait, and pain in the hip joint with passive ROM.; Radiographic evidence documenting avascular necrosis stage II or III, or moderate/severe osteoarthritis or rheumatoid arthritis (Tonnis grade 2 or 3).; For diabetic members: HbA1c less than 8 percent within 3 months prior to hip arthroplasty.; For persons with significant conditions or comorbidities: risk/benefit of THA appropriately addressed in the medical record.; For revision/replacement: imaging confirmation of the specific indication, and medical record addressing the revision contraindications.; For iliopsoas tenotomy/lengthening: documentation of failure of at least 6 weeks of formal in-person physical therapy in the past year and at least 1 therapeutic injection with significant but temporary benefit in the past 6 months. Policy exclusions and limitations: Augmented or virtual reality (AR/VR) assistance for hip arthroplasty is considered experimental, investigational, or unproven because its effectiveness has not been established.; Computer-assisted surgical navigation (e.g., MAKOplasty / MAKO Tactile Guidance System) for total hip replacement (THR) is considered experimental, investigational, or unproven because there is a lack of reliable evidence that it improves clinical outcomes of THA. (Note: when robotic assistance is integral to the procedure, it is not separately reimbursed.); Custom joint implants and/or instrumentation are considered experimental, investigational, or unproven (except an FDA-approved custom-made implant for Paprosky type III acetabular defects in members meeting revision THA criteria, which is covered).; Measurement of synovial C-reactive protein, and the alpha-defensin test (Synovasure), as a marker for peri-prosthetic infection in THA, is considered experimental, investigational, or unproven.; Obturator nerve blocks for management of post-operative pain following THA are considered experimental, investigational, or unproven.; Pre-operative advanced imaging that is required for any experimental, investigational, or unproven procedure (e.g., computer-assisted navigation, robotic-assisted navigation, customized implants/instrumentation) is considered experimental, investigational, or unproven.; Use of a portable accelerometer-based navigation system is considered experimental, investigational, or unproven because its clinical value has not been established.; Removal and revision surgery due to post-THR metallosis alone, without evidence of loosening or malposition, is considered experimental, investigational, or unproven (insufficient clinical evidence).; THA is NOT medically necessary (absolute contraindications) if the member has ANY of: active infection of the joint or active systemic bacteremia not totally eradicated; OR active skin infection (except recurrent cutaneous staph infections) or open wound within the planned surgical site; OR allergy to implant components (cobalt, chromium, alumina); OR corticosteroid injection into the joint within 12 weeks of the planned arthroplasty; OR paraplegia or quadriplegia; OR permanent or irreversible muscle weakness absent pain preventing ambulation; OR rapidly progressive neurological disease (except concomitant displaced femoral neck fracture); OR skeletal immaturity.; Revision/replacement is NOT medically necessary if the member has ANY of the following (revision contraindications): loss of musculature (in particular hip abductor musculature), neuromuscular compromise, or vascular deficiency in the affected limb rendering the procedure unjustifiable; OR osteoporosis or other osseous abnormalities which would make the likelihood of a poor outcome more probable; OR poor skin coverage; OR severe instability due to anatomic causes that would make the likelihood of a poor surgical outcome more probable.; Revision or replacement of THA or hip resurfacing arthroplasty is NOT medically necessary when the medically necessary revision criteria are not met. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Hip Arthroplasty (Total Hip Implants)?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Note: Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Medical record clearly addressing the history and results of conservative (non-surgical) therapy, including duration (at least 12 weeks; at least 24 weeks for persons with a relative contraindication).; Formal in-person physical therapy confirmed either by the actual PT notes or by documentation in the member claims history.; Where conservative therapy is not appropriate, medical record documentation clearly explaining why such an approach is not reasonable.; Physical examination findings documenting limited range of motion, antalgic gait, and pain in the hip joint with passive ROM.; Radiographic evidence documenting avascular necrosis stage II or III, or moderate/severe osteoarthritis or rheumatoid arthritis (Tonnis grade 2 or 3).; For diabetic members: HbA1c less than 8 percent within 3 months prior to hip arthroplasty.; For persons with significant conditions or comorbidities: risk/benefit of THA appropriately addressed in the medical record.; For revision/replacement: imaging confirmation of the specific indication, and medical record addressing the revision contraindications.; For iliopsoas tenotomy/lengthening: documentation of failure of at least 6 weeks of formal in-person physical therapy in the past year and at least 1 therapeutic injection with significant but temporary benefit in the past 6 months.

What does Aetna exclude for Hip Arthroplasty (Total Hip Implants)?

Policy exclusions and limitations: Augmented or virtual reality (AR/VR) assistance for hip arthroplasty is considered experimental, investigational, or unproven because its effectiveness has not been established.; Computer-assisted surgical navigation (e.g., MAKOplasty / MAKO Tactile Guidance System) for total hip replacement (THR) is considered experimental, investigational, or unproven because there is a lack of reliable evidence that it improves clinical outcomes of THA. (Note: when robotic assistance is integral to the procedure, it is not separately reimbursed.); Custom joint implants and/or instrumentation are considered experimental, investigational, or unproven (except an FDA-approved custom-made implant for Paprosky type III acetabular defects in members meeting revision THA criteria, which is covered).; Measurement of synovial C-reactive protein, and the alpha-defensin test (Synovasure), as a marker for peri-prosthetic infection in THA, is considered experimental, investigational, or unproven.; Obturator nerve blocks for management of post-operative pain following THA are considered experimental, investigational, or unproven.; Pre-operative advanced imaging that is required for any experimental, investigational, or unproven procedure (e.g., computer-assisted navigation, robotic-assisted navigation, customized implants/instrumentation) is considered experimental, investigational, or unproven.; Use of a portable accelerometer-based navigation system is considered experimental, investigational, or unproven because its clinical value has not been established.; Removal and revision surgery due to post-THR metallosis alone, without evidence of loosening or malposition, is considered experimental, investigational, or unproven (insufficient clinical evidence).; THA is NOT medically necessary (absolute contraindications) if the member has ANY of: active infection of the joint or active systemic bacteremia not totally eradicated; OR active skin infection (except recurrent cutaneous staph infections) or open wound within the planned surgical site; OR allergy to implant components (cobalt, chromium, alumina); OR corticosteroid injection into the joint within 12 weeks of the planned arthroplasty; OR paraplegia or quadriplegia; OR permanent or irreversible muscle weakness absent pain preventing ambulation; OR rapidly progressive neurological disease (except concomitant displaced femoral neck fracture); OR skeletal immaturity.; Revision/replacement is NOT medically necessary if the member has ANY of the following (revision contraindications): loss of musculature (in particular hip abductor musculature), neuromuscular compromise, or vascular deficiency in the affected limb rendering the procedure unjustifiable; OR osteoporosis or other osseous abnormalities which would make the likelihood of a poor outcome more probable; OR poor skin coverage; OR severe instability due to anatomic causes that would make the likelihood of a poor surgical outcome more probable.; Revision or replacement of THA or hip resurfacing arthroplasty is NOT medically necessary when the medically necessary revision criteria are not met. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT