Prior Authorization
Humana Prior Authorization for CPT 27447
Total knee 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 knee arthroplasty. Must demonstrate Kellgren-Lawrence Grade 3-4 on weight-bearing films, 12+ weeks of failed conservative therapy, and functional impairment. Diabetic patients need HbA1c <8%. Active smokers may require cessation documentation. Unicompartmental knee arthroplasty (27446) has separate, less restrictive criteria.
Documentation checklist
- ✓Weight-bearing knee radiographs
- ✓Physical therapy notes (12+ weeks)
- ✓Conservative treatment documentation
- ✓Preoperative medical evaluation
- ✓BMI and HbA1c documentation
Submission channels
Phone
1-800-444-9137Fax
1-877-418-05062026 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). Humana'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 knee radiographs, Physical therapy notes (12+ weeks), Conservative treatment documentation….
- 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 27447?
- Yes. Humana requires prior authorization for CPT 27447 (Total knee arthroplasty) under Standard commercial plans per its published clinical policy.
- What documentation does Humana require for CPT 27447?
- Weight-bearing knee radiographs; Physical therapy notes (12+ weeks); Conservative treatment documentation; Preoperative medical evaluation; BMI and HbA1c documentation
- 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 Humana are typically negotiated against this benchmark.
- What if Humana 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 Humana PA lookups
CPT 27447 prior authorization by payer
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