Aetna · Clinical coverage policy

Aetna Knee Arthroplasty coverage criteria

Aetna CPB 0660 covers knee arthroplasty (total, unicompartmental/partial, and revision) as medically necessary for adults with advanced, symptomatic knee joint disease confirmed on physical exam and imaging (e.g., Kellgren-Lawrence Grade 3-4 osteoarthritis, avascular necrosis, or rheumatoid joint-space narrowing) who have failed at least 12 weeks of conservative therapy (24 weeks for relative contraindications such as BMI greater than 40 or age under 50), with at least half being in-person physical therapy. Coverage requires absence of listed contraindications (e.g., active infection, recent steroid injection, implant allergy), and revisions require an imaging-confirmed indication such as aseptic loosening, periprosthetic fracture, infection, or instability. The bulletin lists numerous experimental/investigational items (e.g., bicompartmental arthroplasty, smart knee implants, computer-assisted navigation/MAKOplasty, tele-rehabilitation) as not covered; precertification may be required for select procedures (check the CPT code search tool).

Policy CPB 0660 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0660

Prior auth

Confirm

Effective

March 16, 1997

This page reflects the coverage criteria captured from Aetna policy CPB 0660 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

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.

When does Aetna cover Knee Arthroplasty (CPT 27447), and what gets it denied?

Path
Aetna CPB 0660 covers knee arthroplasty (total, unicompartmental/partial, and revision) as medically necessary for adults with advanced, symptomatic knee joint disease confirmed on physical exam and imaging (e.g., Kellgren-Lawrence Grade 3-4 osteoarthritis, avascular necrosis, or rheumatoid joint-space narrowing) who have failed at least 12 weeks of conservative therapy (24 weeks for relative contraindications such as BMI greater than 40 or age under 50), with at least half being in-person physical therapy. Coverage requires absence of listed contraindications (e.g., active infection, recent steroid injection, implant allergy), and revisions require an imaging-confirmed indication such as aseptic loosening, periprosthetic fracture, infection, or instability. The bulletin lists numerous experimental/investigational items (e.g., bicompartmental arthroplasty, smart knee implants, computer-assisted navigation/MAKOplasty, tele-rehabilitation) as not covered; precertification may be required for select procedures (check the CPT code search tool). Coverage criteria include: TOTAL KNEE ARTHROPLASTY (TKA): FDA-approved TKA prosthesis is medically necessary for adult members when ALL of the following are met: (1) Advanced joint disease, (2) unsuccessful conservative therapy, AND (3) a qualifying indication (see following items).; TKA — Advanced joint disease (meet ALL of): pain and functional disability interfering with ADLs from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the knee joint; AND limited range of motion, crepitus, or effusion/swelling of the knee on physical examination; AND radiographic evidence (ONE of): moderate/severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4) OR avascular necrosis (osteonecrosis) of tibial or femoral condyle OR rheumatoid arthritis (joint space narrowing).; TKA — History of unsuccessful conservative therapy (non-surgical medical management): at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), clearly addressed in the medical record. At least half of the necessary conservative therapy must consist of formal physical therapy (in-person with a licensed physical therapist; NOT home/virtual).; TKA — Conservative therapy must include ALL of the following (UNLESS contraindicated): anti-inflammatory medications or analgesics; AND flexibility and muscle strengthening exercises; AND activity modification; AND supervised physical therapy (ADLs diminished despite completing plan of care); AND assistive device use (REQUIRED for persons with relative contraindications, optional for others); AND therapeutic injections into the knee (REQUIRED for persons with relative contraindications, optional for others).; TKA — Conservative therapy may be INAPPROPRIATE for (and medical record must clearly document why): severe osteoarthritis with bone-on-bone articulation in the weight-bearing portion (medial/lateral, NOT patellofemoral); OR severe angular deformity; OR avascular necrosis with collapse of tibial or femoral condyle; OR progressive flexion contracture.; TKA — Alternative qualifying indications (ONE of, in lieu of advanced joint disease pathway): failure of previous osteotomy with pain interfering with ADLs; OR distal femur or proximal tibia malunion by imaging with pain interfering with ADLs; OR distal femur or proximal tibia fracture or nonunion; OR malignancy of distal femur, proximal tibia, knee joint or adjacent soft tissues by imaging; OR failure of previous unicompartmental knee replacement with pain interfering with ADLs.; TKA — For members with significant conditions or co-morbidities, the risk/benefit of TKA must be appropriately addressed in the medical record.; TKA — If the member is diabetic, hemoglobin A1C (HbA1c) should be less than 8 percent within 3 months prior to knee arthroplasty.; Prophylactic use of tranexamic acid is medically necessary in TKA to decrease blood loss.; REVISION OR REPLACEMENT OF TOTAL KNEE ARTHROPLASTY: medically necessary when accompanied by pain and functional disability (interference with ADLs) AND ONE of the following indications is present, AND the member does NOT have any listed contraindication.; TKA revision indication: aseptic loosening of one or more prosthetic components confirmed by imaging.; TKA revision indication: fracture of one or more components of the prosthesis, or a worn or dislocated plastic insert, confirmed by imaging.; TKA revision indication: confirmed periprosthetic infection by gram stain and culture. (Note: single-stage revision is considered medically necessary for this indication, UNLESS there was prior infection in the same joint, in which case multi-stage revision may be medically necessary.); TKA revision indication: periprosthetic fracture of the distal femur, proximal tibia, or patella confirmed by imaging.; TKA revision indication: progressive or substantial periprosthetic bone loss confirmed by imaging.; TKA revision indication: bearing surface wear leading to symptomatic synovitis.; TKA revision indication: implant or knee malalignment (valgus/varus or flexion/extension greater than 15 degrees).; TKA revision indication: knee arthrofibrosis.; TKA revision indication: instability or dislocation of the TKA.; TKA revision indication: extensor mechanism instability.; TKA revision — member must NOT have ANY of the following contraindications: poor bone quality; OR highly limited quadriceps or extensor function; OR poor skin coverage; OR poor vascular status.; UNICOMPARTMENTAL KNEE ARTHROPLASTY (UKA): using FDA-approved devices, medically necessary for members with advanced osteoarthritis or post-traumatic arthritis affecting only a single compartment (medial, lateral, or patellofemoral) when ALL of the following criteria are met.; UKA criterion: pain and functional disability interfering with ADLs due to osteoarthritis or post-traumatic arthritis of the knee joint.; UKA criterion: limited range of motion, crepitus, or effusion/swelling of the knee joint on physical examination.; UKA criterion: intact, stable ligaments, in particular the anterior cruciate ligament.; UKA criterion: knee arc of motion (full extension to full flexion) NOT limited to 90 degrees or less.; UKA criterion: radiographic evidence of moderate/severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4) affecting only a single (medial, lateral, or patellofemoral) compartment of the knee joint.; UKA criterion — History of unsuccessful conservative therapy: non-surgical medical management of 12 weeks (or 24 weeks for relative contraindications, depending on age/BMI), clearly addressed in the medical record; at least half consisting of formal physical therapy (in-person with a licensed physical therapist, NOT home/virtual), confirmed by actual PT notes or documentation in member claims history. May be inappropriate for severe osteoarthritis with bone-on-bone articulation in the weight-bearing portion (medial/lateral, NOT patellofemoral).; UKA — Conservative therapy includes ALL of the following (UNLESS contraindicated): anti-inflammatory medications or analgesics; AND flexibility and muscle strengthening exercises; AND activity modification; AND supervised physical therapy (ADLs diminished despite completing plan of care); AND assistive device use (REQUIRED for relative contraindications, optional for others); AND therapeutic injections into the knee (REQUIRED for relative contraindications, optional for others).; UKA — member must have NONE of the following contraindications to UKA: previous proximal tibial osteotomy or distal femoral osteotomy; OR tibial or femoral shaft deformity; OR radiographic evidence of medial or lateral subluxation; OR flexion contracture greater than 15 degrees; OR varus deformity greater than 15 degrees (medial UKA) OR valgus deformity greater than 20 degrees (lateral UKA); OR inflammatory or crystalline arthropathy; OR subchondral bone loss due to large subchondral cysts or extensive focal osteonecrosis.; UKA — member must have NONE of the absolute contraindications to joint replacement (see exclusions list).; UKA — For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.; RELATIVE CONTRAINDICATIONS to joint replacement (members with these should exhaust ALL nonsurgical treatment options, i.e., the 24-week conservative-therapy pathway applies): morbid obesity (BMI greater than 40); age less than 50 years.. Applies to 11 codes: 27447, 27446, 27440, 27441, 27442, 27443, 27437, 27438, 27486, 27487, 27488.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Conservative therapy: at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), with at least half consisting of formal physical therapy (in-person with a licensed physical therapist).; Physical therapy must be confirmed either by actual PT notes OR by documentation in member claims history.; If claiming that conservative therapy is inappropriate/not reasonable (due to severe conditions), the medical record must clearly document why.; Radiographic/imaging evidence supporting the diagnosis (grade of osteoarthritis, avascular necrosis, or rheumatoid arthritis; for revision, imaging confirmation of the qualifying indication).; For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.; For diabetic members, HbA1c less than 8 percent within 3 months prior to the procedure.
Trap
Policy exclusions and limitations: Absolute contraindication to TKA (NOT medically necessary): active infection of the joint or active systemic bacteremia not totally eradicated.; Absolute contraindication to TKA (NOT medically necessary): active skin infection (exception: recurrent cutaneous staph infections) or open wound within the planned surgical site of the knee.; Absolute contraindication to TKA (NOT medically necessary): corticosteroid injection into the joint within 12 weeks of planned arthroplasty.; Absolute contraindication to TKA (NOT medically necessary): vascular insufficiency, significant muscular atrophy of the leg, or neuromuscular disease severe enough to compromise implant stability or post-operative recovery, or quadriplegia.; Absolute contraindication to TKA (NOT medically necessary): osseous abnormalities that cannot be optimally managed and increase the likelihood of a poor surgical outcome (inadequate bone stock to support the implant).; Absolute contraindication to TKA (NOT medically necessary): allergy to components of the implant (e.g., cobalt, chromium, or alumina).; Experimental, investigational, or unproven: bacteriophage therapy for knee arthroplasty-related peri-prosthetic joint infection.; Experimental, investigational, or unproven: bicompartmental, staged bicompartmental, and bi-unicompartmental knee arthroplasty for osteoarthritis and all other indications.; Experimental, investigational, or unproven: custom instrumentation for the procedure including cutting blocks.; Experimental, investigational, or unproven: customized total or partial knee implant.; Experimental, investigational, or unproven: genicular nerve radiofrequency ablation for peri-operative pain control in TKA and for treatment of chronic pain in a well-appearing TKA.; Experimental, investigational, or unproven: mineralized collagen-enhanced bone cement for TKA.; Experimental, investigational, or unproven: prophylactic radiation therapy following TKA.; Experimental, investigational, or unproven: 'Smart Knee Implants' (e.g., Zimmer Persona IQ).; Experimental, investigational, or unproven: tele-rehabilitation after TKA.; Experimental, investigational, or unproven: UniSpacer inter-positional spacer for treatment of osteoarthritis affecting the medial compartment of the knee.; Experimental, investigational, or unproven: augmented or virtual reality (AR/VR) assistance for knee arthroplasty.; Experimental, investigational, or unproven: computer-assisted musculoskeletal surgical navigation (e.g., MAKOplasty) — lacks reliable evidence that it improves surgical outcomes. (Note: robotic assistance is considered integral to the primary procedure and is not separately reimbursed.); Experimental, investigational, or unproven: pre-operative advanced imaging where required for any experimental, investigational, or unproven procedure.; Not separately reimbursable: intra-operative kinetic balance sensor for implant stability during knee replacement is considered incidental to the primary procedure and not eligible for separate reimbursement. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0660 — Knee Arthroplasty

Coverage criteria

  • TOTAL KNEE ARTHROPLASTY (TKA): FDA-approved TKA prosthesis is medically necessary for adult members when ALL of the following are met: (1) Advanced joint disease, (2) unsuccessful conservative therapy, AND (3) a qualifying indication (see following items).
  • TKA — Advanced joint disease (meet ALL of): pain and functional disability interfering with ADLs from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the knee joint; AND limited range of motion, crepitus, or effusion/swelling of the knee on physical examination; AND radiographic evidence (ONE of): moderate/severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4) OR avascular necrosis (osteonecrosis) of tibial or femoral condyle OR rheumatoid arthritis (joint space narrowing).
  • TKA — History of unsuccessful conservative therapy (non-surgical medical management): at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), clearly addressed in the medical record. At least half of the necessary conservative therapy must consist of formal physical therapy (in-person with a licensed physical therapist; NOT home/virtual).
  • TKA — Conservative therapy must include ALL of the following (UNLESS contraindicated): anti-inflammatory medications or analgesics; AND flexibility and muscle strengthening exercises; AND activity modification; AND supervised physical therapy (ADLs diminished despite completing plan of care); AND assistive device use (REQUIRED for persons with relative contraindications, optional for others); AND therapeutic injections into the knee (REQUIRED for persons with relative contraindications, optional for others).
  • TKA — Conservative therapy may be INAPPROPRIATE for (and medical record must clearly document why): severe osteoarthritis with bone-on-bone articulation in the weight-bearing portion (medial/lateral, NOT patellofemoral); OR severe angular deformity; OR avascular necrosis with collapse of tibial or femoral condyle; OR progressive flexion contracture.
  • TKA — Alternative qualifying indications (ONE of, in lieu of advanced joint disease pathway): failure of previous osteotomy with pain interfering with ADLs; OR distal femur or proximal tibia malunion by imaging with pain interfering with ADLs; OR distal femur or proximal tibia fracture or nonunion; OR malignancy of distal femur, proximal tibia, knee joint or adjacent soft tissues by imaging; OR failure of previous unicompartmental knee replacement with pain interfering with ADLs.
  • TKA — For members with significant conditions or co-morbidities, the risk/benefit of TKA must be appropriately addressed in the medical record.
  • TKA — If the member is diabetic, hemoglobin A1C (HbA1c) should be less than 8 percent within 3 months prior to knee arthroplasty.
  • Prophylactic use of tranexamic acid is medically necessary in TKA to decrease blood loss.
  • REVISION OR REPLACEMENT OF TOTAL KNEE ARTHROPLASTY: medically necessary when accompanied by pain and functional disability (interference with ADLs) AND ONE of the following indications is present, AND the member does NOT have any listed contraindication.
  • TKA revision indication: aseptic loosening of one or more prosthetic components confirmed by imaging.
  • TKA revision indication: fracture of one or more components of the prosthesis, or a worn or dislocated plastic insert, confirmed by imaging.
  • TKA revision indication: confirmed periprosthetic infection by gram stain and culture. (Note: single-stage revision is considered medically necessary for this indication, UNLESS there was prior infection in the same joint, in which case multi-stage revision may be medically necessary.)
  • TKA revision indication: periprosthetic fracture of the distal femur, proximal tibia, or patella confirmed by imaging.
  • TKA revision indication: progressive or substantial periprosthetic bone loss confirmed by imaging.
  • TKA revision indication: bearing surface wear leading to symptomatic synovitis.
  • TKA revision indication: implant or knee malalignment (valgus/varus or flexion/extension greater than 15 degrees).
  • TKA revision indication: knee arthrofibrosis.
  • TKA revision indication: instability or dislocation of the TKA.
  • TKA revision indication: extensor mechanism instability.
  • TKA revision — member must NOT have ANY of the following contraindications: poor bone quality; OR highly limited quadriceps or extensor function; OR poor skin coverage; OR poor vascular status.
  • UNICOMPARTMENTAL KNEE ARTHROPLASTY (UKA): using FDA-approved devices, medically necessary for members with advanced osteoarthritis or post-traumatic arthritis affecting only a single compartment (medial, lateral, or patellofemoral) when ALL of the following criteria are met.
  • UKA criterion: pain and functional disability interfering with ADLs due to osteoarthritis or post-traumatic arthritis of the knee joint.
  • UKA criterion: limited range of motion, crepitus, or effusion/swelling of the knee joint on physical examination.
  • UKA criterion: intact, stable ligaments, in particular the anterior cruciate ligament.
  • UKA criterion: knee arc of motion (full extension to full flexion) NOT limited to 90 degrees or less.
  • UKA criterion: radiographic evidence of moderate/severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4) affecting only a single (medial, lateral, or patellofemoral) compartment of the knee joint.
  • UKA criterion — History of unsuccessful conservative therapy: non-surgical medical management of 12 weeks (or 24 weeks for relative contraindications, depending on age/BMI), clearly addressed in the medical record; at least half consisting of formal physical therapy (in-person with a licensed physical therapist, NOT home/virtual), confirmed by actual PT notes or documentation in member claims history. May be inappropriate for severe osteoarthritis with bone-on-bone articulation in the weight-bearing portion (medial/lateral, NOT patellofemoral).
  • UKA — Conservative therapy includes ALL of the following (UNLESS contraindicated): anti-inflammatory medications or analgesics; AND flexibility and muscle strengthening exercises; AND activity modification; AND supervised physical therapy (ADLs diminished despite completing plan of care); AND assistive device use (REQUIRED for relative contraindications, optional for others); AND therapeutic injections into the knee (REQUIRED for relative contraindications, optional for others).
  • UKA — member must have NONE of the following contraindications to UKA: previous proximal tibial osteotomy or distal femoral osteotomy; OR tibial or femoral shaft deformity; OR radiographic evidence of medial or lateral subluxation; OR flexion contracture greater than 15 degrees; OR varus deformity greater than 15 degrees (medial UKA) OR valgus deformity greater than 20 degrees (lateral UKA); OR inflammatory or crystalline arthropathy; OR subchondral bone loss due to large subchondral cysts or extensive focal osteonecrosis.
  • UKA — member must have NONE of the absolute contraindications to joint replacement (see exclusions list).
  • UKA — For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.
  • RELATIVE CONTRAINDICATIONS to joint replacement (members with these should exhaust ALL nonsurgical treatment options, i.e., the 24-week conservative-therapy pathway applies): morbid obesity (BMI greater than 40); age less than 50 years.

Covered codes

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

Documentation required

  • Conservative therapy: at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), with at least half consisting of formal physical therapy (in-person with a licensed physical therapist).
  • Physical therapy must be confirmed either by actual PT notes OR by documentation in member claims history.
  • If claiming that conservative therapy is inappropriate/not reasonable (due to severe conditions), the medical record must clearly document why.
  • Radiographic/imaging evidence supporting the diagnosis (grade of osteoarthritis, avascular necrosis, or rheumatoid arthritis; for revision, imaging confirmation of the qualifying indication).
  • For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.
  • For diabetic members, HbA1c less than 8 percent within 3 months prior to the procedure.

Frequently asked questions

When does Aetna cover Knee Arthroplasty (CPT 27447), and what gets it denied?
Aetna CPB 0660 covers knee arthroplasty (total, unicompartmental/partial, and revision) as medically necessary for adults with advanced, symptomatic knee joint disease confirmed on physical exam and imaging (e.g., Kellgren-Lawrence Grade 3-4 osteoarthritis, avascular necrosis, or rheumatoid joint-space narrowing) who have failed at least 12 weeks of conservative therapy (24 weeks for relative contraindications such as BMI greater than 40 or age under 50), with at least half being in-person physical therapy. Coverage requires absence of listed contraindications (e.g., active infection, recent steroid injection, implant allergy), and revisions require an imaging-confirmed indication such as aseptic loosening, periprosthetic fracture, infection, or instability. The bulletin lists numerous experimental/investigational items (e.g., bicompartmental arthroplasty, smart knee implants, computer-assisted navigation/MAKOplasty, tele-rehabilitation) as not covered; precertification may be required for select procedures (check the CPT code search tool). Coverage criteria include: TOTAL KNEE ARTHROPLASTY (TKA): FDA-approved TKA prosthesis is medically necessary for adult members when ALL of the following are met: (1) Advanced joint disease, (2) unsuccessful conservative therapy, AND (3) a qualifying indication (see following items).; TKA — Advanced joint disease (meet ALL of): pain and functional disability interfering with ADLs from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the knee joint; AND limited range of motion, crepitus, or effusion/swelling of the knee on physical examination; AND radiographic evidence (ONE of): moderate/severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4) OR avascular necrosis (osteonecrosis) of tibial or femoral condyle OR rheumatoid arthritis (joint space narrowing).; TKA — History of unsuccessful conservative therapy (non-surgical medical management): at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), clearly addressed in the medical record. At least half of the necessary conservative therapy must consist of formal physical therapy (in-person with a licensed physical therapist; NOT home/virtual).; TKA — Conservative therapy must include ALL of the following (UNLESS contraindicated): anti-inflammatory medications or analgesics; AND flexibility and muscle strengthening exercises; AND activity modification; AND supervised physical therapy (ADLs diminished despite completing plan of care); AND assistive device use (REQUIRED for persons with relative contraindications, optional for others); AND therapeutic injections into the knee (REQUIRED for persons with relative contraindications, optional for others).; TKA — Conservative therapy may be INAPPROPRIATE for (and medical record must clearly document why): severe osteoarthritis with bone-on-bone articulation in the weight-bearing portion (medial/lateral, NOT patellofemoral); OR severe angular deformity; OR avascular necrosis with collapse of tibial or femoral condyle; OR progressive flexion contracture.; TKA — Alternative qualifying indications (ONE of, in lieu of advanced joint disease pathway): failure of previous osteotomy with pain interfering with ADLs; OR distal femur or proximal tibia malunion by imaging with pain interfering with ADLs; OR distal femur or proximal tibia fracture or nonunion; OR malignancy of distal femur, proximal tibia, knee joint or adjacent soft tissues by imaging; OR failure of previous unicompartmental knee replacement with pain interfering with ADLs.; TKA — For members with significant conditions or co-morbidities, the risk/benefit of TKA must be appropriately addressed in the medical record.; TKA — If the member is diabetic, hemoglobin A1C (HbA1c) should be less than 8 percent within 3 months prior to knee arthroplasty.; Prophylactic use of tranexamic acid is medically necessary in TKA to decrease blood loss.; REVISION OR REPLACEMENT OF TOTAL KNEE ARTHROPLASTY: medically necessary when accompanied by pain and functional disability (interference with ADLs) AND ONE of the following indications is present, AND the member does NOT have any listed contraindication.; TKA revision indication: aseptic loosening of one or more prosthetic components confirmed by imaging.; TKA revision indication: fracture of one or more components of the prosthesis, or a worn or dislocated plastic insert, confirmed by imaging.; TKA revision indication: confirmed periprosthetic infection by gram stain and culture. (Note: single-stage revision is considered medically necessary for this indication, UNLESS there was prior infection in the same joint, in which case multi-stage revision may be medically necessary.); TKA revision indication: periprosthetic fracture of the distal femur, proximal tibia, or patella confirmed by imaging.; TKA revision indication: progressive or substantial periprosthetic bone loss confirmed by imaging.; TKA revision indication: bearing surface wear leading to symptomatic synovitis.; TKA revision indication: implant or knee malalignment (valgus/varus or flexion/extension greater than 15 degrees).; TKA revision indication: knee arthrofibrosis.; TKA revision indication: instability or dislocation of the TKA.; TKA revision indication: extensor mechanism instability.; TKA revision — member must NOT have ANY of the following contraindications: poor bone quality; OR highly limited quadriceps or extensor function; OR poor skin coverage; OR poor vascular status.; UNICOMPARTMENTAL KNEE ARTHROPLASTY (UKA): using FDA-approved devices, medically necessary for members with advanced osteoarthritis or post-traumatic arthritis affecting only a single compartment (medial, lateral, or patellofemoral) when ALL of the following criteria are met.; UKA criterion: pain and functional disability interfering with ADLs due to osteoarthritis or post-traumatic arthritis of the knee joint.; UKA criterion: limited range of motion, crepitus, or effusion/swelling of the knee joint on physical examination.; UKA criterion: intact, stable ligaments, in particular the anterior cruciate ligament.; UKA criterion: knee arc of motion (full extension to full flexion) NOT limited to 90 degrees or less.; UKA criterion: radiographic evidence of moderate/severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4) affecting only a single (medial, lateral, or patellofemoral) compartment of the knee joint.; UKA criterion — History of unsuccessful conservative therapy: non-surgical medical management of 12 weeks (or 24 weeks for relative contraindications, depending on age/BMI), clearly addressed in the medical record; at least half consisting of formal physical therapy (in-person with a licensed physical therapist, NOT home/virtual), confirmed by actual PT notes or documentation in member claims history. May be inappropriate for severe osteoarthritis with bone-on-bone articulation in the weight-bearing portion (medial/lateral, NOT patellofemoral).; UKA — Conservative therapy includes ALL of the following (UNLESS contraindicated): anti-inflammatory medications or analgesics; AND flexibility and muscle strengthening exercises; AND activity modification; AND supervised physical therapy (ADLs diminished despite completing plan of care); AND assistive device use (REQUIRED for relative contraindications, optional for others); AND therapeutic injections into the knee (REQUIRED for relative contraindications, optional for others).; UKA — member must have NONE of the following contraindications to UKA: previous proximal tibial osteotomy or distal femoral osteotomy; OR tibial or femoral shaft deformity; OR radiographic evidence of medial or lateral subluxation; OR flexion contracture greater than 15 degrees; OR varus deformity greater than 15 degrees (medial UKA) OR valgus deformity greater than 20 degrees (lateral UKA); OR inflammatory or crystalline arthropathy; OR subchondral bone loss due to large subchondral cysts or extensive focal osteonecrosis.; UKA — member must have NONE of the absolute contraindications to joint replacement (see exclusions list).; UKA — For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.; RELATIVE CONTRAINDICATIONS to joint replacement (members with these should exhaust ALL nonsurgical treatment options, i.e., the 24-week conservative-therapy pathway applies): morbid obesity (BMI greater than 40); age less than 50 years.. Applies to 11 codes: 27447, 27446, 27440, 27441, 27442, 27443, 27437, 27438, 27486, 27487, 27488. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Conservative therapy: at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), with at least half consisting of formal physical therapy (in-person with a licensed physical therapist).; Physical therapy must be confirmed either by actual PT notes OR by documentation in member claims history.; If claiming that conservative therapy is inappropriate/not reasonable (due to severe conditions), the medical record must clearly document why.; Radiographic/imaging evidence supporting the diagnosis (grade of osteoarthritis, avascular necrosis, or rheumatoid arthritis; for revision, imaging confirmation of the qualifying indication).; For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.; For diabetic members, HbA1c less than 8 percent within 3 months prior to the procedure. Policy exclusions and limitations: Absolute contraindication to TKA (NOT medically necessary): active infection of the joint or active systemic bacteremia not totally eradicated.; Absolute contraindication to TKA (NOT medically necessary): active skin infection (exception: recurrent cutaneous staph infections) or open wound within the planned surgical site of the knee.; Absolute contraindication to TKA (NOT medically necessary): corticosteroid injection into the joint within 12 weeks of planned arthroplasty.; Absolute contraindication to TKA (NOT medically necessary): vascular insufficiency, significant muscular atrophy of the leg, or neuromuscular disease severe enough to compromise implant stability or post-operative recovery, or quadriplegia.; Absolute contraindication to TKA (NOT medically necessary): osseous abnormalities that cannot be optimally managed and increase the likelihood of a poor surgical outcome (inadequate bone stock to support the implant).; Absolute contraindication to TKA (NOT medically necessary): allergy to components of the implant (e.g., cobalt, chromium, or alumina).; Experimental, investigational, or unproven: bacteriophage therapy for knee arthroplasty-related peri-prosthetic joint infection.; Experimental, investigational, or unproven: bicompartmental, staged bicompartmental, and bi-unicompartmental knee arthroplasty for osteoarthritis and all other indications.; Experimental, investigational, or unproven: custom instrumentation for the procedure including cutting blocks.; Experimental, investigational, or unproven: customized total or partial knee implant.; Experimental, investigational, or unproven: genicular nerve radiofrequency ablation for peri-operative pain control in TKA and for treatment of chronic pain in a well-appearing TKA.; Experimental, investigational, or unproven: mineralized collagen-enhanced bone cement for TKA.; Experimental, investigational, or unproven: prophylactic radiation therapy following TKA.; Experimental, investigational, or unproven: 'Smart Knee Implants' (e.g., Zimmer Persona IQ).; Experimental, investigational, or unproven: tele-rehabilitation after TKA.; Experimental, investigational, or unproven: UniSpacer inter-positional spacer for treatment of osteoarthritis affecting the medial compartment of the knee.; Experimental, investigational, or unproven: augmented or virtual reality (AR/VR) assistance for knee arthroplasty.; Experimental, investigational, or unproven: computer-assisted musculoskeletal surgical navigation (e.g., MAKOplasty) — lacks reliable evidence that it improves surgical outcomes. (Note: robotic assistance is considered integral to the primary procedure and is not separately reimbursed.); Experimental, investigational, or unproven: pre-operative advanced imaging where required for any experimental, investigational, or unproven procedure.; Not separately reimbursable: intra-operative kinetic balance sensor for implant stability during knee replacement is considered incidental to the primary procedure and not eligible for separate reimbursement. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Knee Arthroplasty?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Documentation: Conservative therapy: at least 12 weeks of non-surgical treatment documented (24 weeks for persons with relative contraindications), with at least half consisting of formal physical therapy (in-person with a licensed physical therapist).; Physical therapy must be confirmed either by actual PT notes OR by documentation in member claims history.; If claiming that conservative therapy is inappropriate/not reasonable (due to severe conditions), the medical record must clearly document why.; Radiographic/imaging evidence supporting the diagnosis (grade of osteoarthritis, avascular necrosis, or rheumatoid arthritis; for revision, imaging confirmation of the qualifying indication).; For members with significant conditions or co-morbidities, the risk/benefit must be appropriately addressed in the medical record.; For diabetic members, HbA1c less than 8 percent within 3 months prior to the procedure.
What does Aetna exclude for Knee Arthroplasty?
Policy exclusions and limitations: Absolute contraindication to TKA (NOT medically necessary): active infection of the joint or active systemic bacteremia not totally eradicated.; Absolute contraindication to TKA (NOT medically necessary): active skin infection (exception: recurrent cutaneous staph infections) or open wound within the planned surgical site of the knee.; Absolute contraindication to TKA (NOT medically necessary): corticosteroid injection into the joint within 12 weeks of planned arthroplasty.; Absolute contraindication to TKA (NOT medically necessary): vascular insufficiency, significant muscular atrophy of the leg, or neuromuscular disease severe enough to compromise implant stability or post-operative recovery, or quadriplegia.; Absolute contraindication to TKA (NOT medically necessary): osseous abnormalities that cannot be optimally managed and increase the likelihood of a poor surgical outcome (inadequate bone stock to support the implant).; Absolute contraindication to TKA (NOT medically necessary): allergy to components of the implant (e.g., cobalt, chromium, or alumina).; Experimental, investigational, or unproven: bacteriophage therapy for knee arthroplasty-related peri-prosthetic joint infection.; Experimental, investigational, or unproven: bicompartmental, staged bicompartmental, and bi-unicompartmental knee arthroplasty for osteoarthritis and all other indications.; Experimental, investigational, or unproven: custom instrumentation for the procedure including cutting blocks.; Experimental, investigational, or unproven: customized total or partial knee implant.; Experimental, investigational, or unproven: genicular nerve radiofrequency ablation for peri-operative pain control in TKA and for treatment of chronic pain in a well-appearing TKA.; Experimental, investigational, or unproven: mineralized collagen-enhanced bone cement for TKA.; Experimental, investigational, or unproven: prophylactic radiation therapy following TKA.; Experimental, investigational, or unproven: 'Smart Knee Implants' (e.g., Zimmer Persona IQ).; Experimental, investigational, or unproven: tele-rehabilitation after TKA.; Experimental, investigational, or unproven: UniSpacer inter-positional spacer for treatment of osteoarthritis affecting the medial compartment of the knee.; Experimental, investigational, or unproven: augmented or virtual reality (AR/VR) assistance for knee arthroplasty.; Experimental, investigational, or unproven: computer-assisted musculoskeletal surgical navigation (e.g., MAKOplasty) — lacks reliable evidence that it improves surgical outcomes. (Note: robotic assistance is considered integral to the primary procedure and is not separately reimbursed.); Experimental, investigational, or unproven: pre-operative advanced imaging where required for any experimental, investigational, or unproven procedure.; Not separately reimbursable: intra-operative kinetic balance sensor for implant stability during knee replacement is considered incidental to the primary procedure and not eligible for separate reimbursement. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0660 — Knee Arthroplasty

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0660 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.