Prior Authorization
Anthem Prior Authorization for CPT 27447
Total knee arthroplasty · Standard commercial plans
Source
Anthem clinical policyNot 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 knee arthroplasty. Criteria include radiographic evidence of Grade 3-4 OA, 3+ months of failed conservative management (PT, NSAIDs, injections), documented functional limitation, and preoperative medical optimization. Robotic-assisted TKA is covered when TKA criteria are met. Bicompartmental knee arthroplasty is investigational.
Documentation checklist
- ✓Weight-bearing X-rays
- ✓Conservative treatment records (3+ months)
- ✓Physical therapy documentation
- ✓Medical clearance
- ✓Functional assessment
Submission channels
Phone
1-800-274-77672026 Medicare rate for CPT 27447
Office (non-facility)
$1159.35
Facility
$1159.35
Total RVUs (office)
34.71
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 27447 code page.
How to submit the PA
- 1Verify the requirement against the current clinical policy linked above.
- 2Gather documentation: Weight-bearing X-rays, Conservative treatment records (3+ months), Physical therapy documentation….
- 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 27447?
- Yes. Anthem requires prior authorization for CPT 27447 (Total knee arthroplasty) under Standard commercial plans per its published clinical policy.
- What documentation does Anthem require for CPT 27447?
- Weight-bearing X-rays; Conservative treatment records (3+ months); Physical therapy documentation; Medical clearance; Functional assessment
- How much does Medicare pay for CPT 27447 in 2026?
- In 2026, the national Medicare allowable for CPT 27447 is $1159.35 in an office setting and $1159.35 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
- What if Anthem denies the PA for CPT 27447?
- 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
CPT 27447 prior authorization by payer
Draft the Anthem PA request for CPT 27447 — free
Ask D3 builds a payer-ready prior-authorization request with the right criteria language and documentation — backed by CMS, Medicare, and major-payer data. No signup.