Important Update: New Medical Record Documentation Requirements for Hip and Knee Surgeries
Before authorization for Total Joint Replacement procedures under codes 27445, 27447, 27130 & 27132
in UnitedHealthcare’s commercial plans, additional information may be requested from the submitting
healthcare provider. It relates to all the fully insured and self-funded health plans in the country.
The evaluation of these requests will be conducted by the following policies:
- Commercial and Individual Exchange Medical Policy on Hip Surgery
- Commercial and Individual Exchange Medical Policy on Knee Surgery
Summary of Required Documentation Changes: For hip surgeries, healthcare providers must include:
- A complete diagnostic imaging report which should be different from notes from an Evaluation
and Management office visit. - If required, copies of specific diagnostic images that show the areas that require surgery, MRI,
CT scans, X-rays, band one scans. It is possible to ask the surgeon who requested help in
selecting the right images.
For knee surgeries, the medical documentation should include:
- A separate service from the Evaluation and Management office visit, consisting of a complete
diagnostic imaging report. - Other aspects include documented skeletal plate closure in the case where the patient was
below the age of 18, presence or absence of articular cartilage defects, size and location of the
cartilage defects, Outerbridge grading, joint space and alignment, location, and grade of
ligament tears. - Specific diagnostic images showing the abnormalities necessitating surgery may also be
requested, and consultation with the requesting surgeon could be advantageous to determine
the optimal imaging techniques.
Conservative Care Requirements
These remain unchanged and should be documented, detailing the treatments used along with their
timing and duration:
- NSAIDs or acetaminophen for a minimum of 3 weeks.
- Physical therapy or a structured home exercise regimen for at least 12 weeks.
- Modifications in activities for a minimum of 12 weeks.
- For knee replacements specifically, at least one intra-articular corticosteroid injection may
substitute for NSAIDs if necessary.
Further Guidance: For more detailed information, providers are advised to consult the relevant
UnitedHealthcare Commercial Policies on hip and knee surgeries.
