Does Anthem require prior authorization for CPT 27130?

Yes. Anthem requires prior authorization for CPT 27130 (Total hip arthroplasty) under Standard commercial plans per its published clinical policy.

What documentation does Anthem require for CPT 27130?

Hip X-rays (AP pelvis, lateral); Conservative treatment documentation; PT records; Medical evaluation

How much does Medicare pay for CPT 27130 in 2026?

In 2026, the national Medicare allowable for CPT 27130 is $1162.02 in an office setting and $1162.02 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 27130?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 27130

Total hip arthroplasty · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for total hip arthroplasty. Must demonstrate advanced degenerative joint disease on imaging, 3+ months of failed conservative management, and documented functional impairment. Fracture and AVN indications have separate, less restrictive criteria. Hip resurfacing is covered under separate policy criteria.

Documentation checklist

✓Hip X-rays (AP pelvis, lateral)
✓Conservative treatment documentation
✓PT records
✓Medical evaluation

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 27130

Office (non-facility)

$1162.02

Facility

$1162.02

Total RVUs (office)

34.79

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 27130 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Hip X-rays (AP pelvis, lateral), Conservative treatment documentation, PT records….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 27130?: Yes. Anthem requires prior authorization for CPT 27130 (Total hip arthroplasty) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 27130?: Hip X-rays (AP pelvis, lateral); Conservative treatment documentation; PT records; Medical evaluation
How much does Medicare pay for CPT 27130 in 2026?: In 2026, the national Medicare allowable for CPT 27130 is $1162.02 in an office setting and $1162.02 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 27130?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

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