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Hip replacement prior authorization

Is Preauth Required? Prior authorization justifications for hip replacement include revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft; revision of total hip arthroplasty; femoral component only, with or without allograft; conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft; revision of total hip arthroplasty; both components, with or without autograft or allograft; hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty); arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft.

Will the claim be denied? Claims for hip replacement may be denied if they do not meet the appropriate use criteria for joint surgery. Specifically, revision total hip arthroplasty is considered medically necessary when at least one of the following conditions is present: aseptic loosening, substantial osteolysis of the weight bearing surface, progressive soft tissue or bone reaction including symptomatic synovitis, component instability, failure, or recall, displaced periprosthetic fracture or irreducible dislocation, previous removal of prosthesis due to infection or catastrophic failure, recurrent disabling pain or significant functional disability that persists despite at least 3 months of conservative management in conjunction with any of the following: antalgic or Trendelenburg gait, abnormal findings confirmed by plain radiography or imaging studies such as implant malposition or impingement, leg length inequality, audible noise. If the condition does not meet any of these criteria, then the claim may be denied.

When is the following treatment medically necessary for the condition specified? Hip replacement is generally considered medically necessary when a patient is experiencing severe pain and immobility due to degenerative joint disease or a hip fracture. It can also be used to treat certain types of hip dislocation or severe hip deformity.

What are the relevant codes for the treatment? The CPT codes for hip replacement are 27130-27134 and the corresponding HCPCS codes are 0332T-0337T.

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