New IFP Rule: Now Requires Medical Records for All Hip and Knee Surgeries
For UnitedHealthcare Individual Exchange plans (also called Individual & Family ACA Marketplace plans), prior authorization is required for total joint replacement procedures. Providers requesting these procedures (CPT codes 27445, 27447, 27130, and 27132) due to osteoarthritis may need to submit additional medical documentation. This applies nationwide, and no new codes are being added to the prior authorization list. Requests will be evaluated based on specific policies.
- Surgery of the Hip — Commercial and Individual Exchange Medical Policy
- Surgery of the Knee — Commercial and Individual Exchange Medical Policy
- Surgery of the Hip – Rocky Mountain Health Plans Medical Policy
- Surgery of the Knee – Rocky Mountain Health Plans Medical Policy
Summary of Changes
Hip Surgery: Providers must submit medical notes that include:
- A complete diagnostic imaging report (e.g., MRI, CT, X-ray, or bone scan) is separate from office visit notes.
- If requested, specific images showing the issue requiring surgery may be needed. Consulting with the surgeon can help choose the best images.
Knee Surgery: Providers must submit medical notes that include:
- A complete diagnostic imaging report separate from office visit notes.
- For patients under 18, documentation of closed skeletal plates.
- Details about any cartilage defects (presence, size, location, Outerbridge grade).
- Information on joint space, alignment, and any ligament tears (location and grade).
- If requested, specific images showing the issue requiring surgery may be needed. Consulting with the surgeon can help select the best images.
Conservative Care Requirements (Unchanged):
Clinical notes should clearly show the following treatments from the past year:
- Use of NSAIDs or acetaminophen for at least 3 weeks.
- Physical therapy or home exercise for at least 12 weeks.
- Activity modification for at least 12 weeks.
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