Prior Authorization
Humana Prior Authorization for CPT 27130
Total hip arthroplasty · Standard commercial plans
Source
Humana Commercial Preauthorization and Notification List (July 2024)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
Humana requires prior authorization for total hip arthroplasty. Must have radiographic evidence of advanced joint disease, 12+ weeks of failed conservative management, and functional limitation interfering with ADLs. Femoral neck fracture and AVN qualify under expedited review. Diabetic patients require HbA1c <8%.
Documentation checklist
- ✓AP pelvis and lateral hip X-rays
- ✓Conservative treatment records
- ✓Physical therapy notes
- ✓Medical clearance
- ✓HbA1c if diabetic
Submission channels
Phone
1-800-444-9137Fax
1-877-418-05062026 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). Humana'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: AP pelvis and lateral hip X-rays, Conservative treatment records, Physical therapy notes….
- 3Submit via phone or fax, or the payer portal.
- 4Document the reference number and follow up within 5 business days if no determination is received.
FAQ
- Does Humana require prior authorization for CPT 27130?
- Yes. Humana requires prior authorization for CPT 27130 (Total hip arthroplasty) under Standard commercial plans per its published clinical policy.
- What documentation does Humana require for CPT 27130?
- AP pelvis and lateral hip X-rays; Conservative treatment records; Physical therapy notes; Medical clearance; HbA1c if diabetic
- 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 Humana are typically negotiated against this benchmark.
- What if Humana 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 Humana PA lookups
CPT 27130 prior authorization by payer
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