General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Purpose
This guideline addresses elective, non-emergent knee arthroplasty (knee replacement) procedures including total knee arthroplasty (TKA), unicompartmental/unicondylar knee arthroplasty (UKA) or hemiarthroplasty (partial knee replacement), and revision arthroplasty procedures.

Scope
Surgical indications are based on relevant subjective clinical symptoms, objective physical exam & radiologic findings, and response to previous non-operative treatments when medically appropriate.

General Requirements

• Elective knee arthroplasty may be considered if the following general criteria are met:
  • Knee pain with documented loss of function, which may include painful weight bearing, painful or inadequate range of motion to accomplish age appropriate activities of daily living (ADLs) and/or employment, and painful mechanical catching, locking, or popping
  • Individual is medically stable and optimized for surgery, and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with a total joint replacement when comorbidities exist as it pertains to the increased risk of complications ⁽¹⁾
  • Individual does not have an active local or systemic infection ⁽²⁾
  • Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, muscle relaxants) unless engaged in treatment program
  • Individual has good oral hygiene and does not have major dental work scheduled or anticipated (ideally within one year of joint replacement), due to increased post-surgical infection risk
• Clinical notes should address:
  • Symptom onset, duration, and severity
  • Loss of function and/or limitations
  • Type and duration of non-operative management modalities
  • Discussion with patient regarding decision making and timing

•  Non-operative management must include at least TWO or more of the following unless otherwise specified in clinical indications below ^(3,4):
  • Rest or activity modifications/limitations
  • Weight reduction for individual with elevated BMI
  • Protected weight-bearing with cane, walker, or crutches
  • Brace/orthosis
  • Physical therapy modalities
  • Physician-supervised exercise program (including home exercise program)
  • Application of heat or ice
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
  • Intra-articular injection(s)

Policy
INDICATIONS
Total Knee Arthroplasty (TKA)
There is no medical necessity to perform TKA in individuals with severe radiological disease and no symptoms. If medical records indicate that possibly either a TKA or a UKA will be performed, based on the findings at the time of surgery, separate requests are to be submitted.

TKA may be considered medically necessary as indicated in either Section One or Section Two ⁽²⁾:

• Section One
  • There is persistent pain and documented loss of function with radiographic evidence of advanced disease from any of the following
    • Rheumatoid arthritis
    • Post-traumatic arthritis (i.e., previous proximal tibia or distal femur fracture causing subsequent arthritis)
    • Fracture
    • Avascular necrosis ⁽⁵⁾ confirmed by imaging (radiographs, MRI, or other advanced imaging)
    • Radiographs (X-rays) demonstrate bone-on-bone articulation

• Section Two
  • There is persistent pain and documented loss of function for at least 12 weeks including all of the following ⁽⁶⁾:
    • Physical exam (PE) findings demonstrate one or more of the following: tenderness, swelling/effusion, limited range of motion (decreased from uninvolved side or as compared to a normal joint), flexion contracture, palpable or audible crepitus, instability and/or angular deformity (PE is not required if bone-on-bone narrowing is present on X-ray)
    • Radiographic findings show evidence of advanced arthritic changes, described as Kellgren-Lawrence grade 3 or grade 4 degeneration or described as X-rays demonstrating advanced changes such as severe narrowing or bone-on-bone compartment collapse, subchondral sclerosis or cysts, osteophyte formation and/or bony deformity. ⁽⁷⁾ X-rays described only as showing 'severe', 'advanced' or 'end-stage' arthritis require more definitive descriptions as stated above. The severity of knee osteoarthritis is commonly determined with weight-bearing radiographs, however, if severe arthritic changes (e.g., bone on bone joint space narrowing) are noted on non-weightbearing images, further weight-bearing radiographs are not required.

NOTE: MRI should not be the primary radiographic test used to determine the presence or severity of arthritic changes in the joint ⁽⁷⁾; likewise, determinations as to the degree of arthritis should not routinely be determined by findings described from prior arthroscopic surgery of the knee

• • • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following ^(3,4):
      • Rest or activity modifications/limitations
      • Weight reduction for individual with elevated BMI
      • Protected weight-bearing with cane, walker, or crutches
      • Brace/orthosis
      • Physical therapy modalities
      • Physician-supervised exercise program (including home exercise program)
      • Application of heat or ice
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
      • Injections: corticosteroid or viscosupplementation
    • No corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}
    • No prior arthroscopic knee surgery within 6 months of surgery ^(12,13,14)

Simultaneous Bilateral TKA

• ALL requests for simultaneous bilateral total knee replacements should clearly indicate why simultaneous TKA is preferable to staged procedures. Associated risks with simultaneous bilateral total knee replacements should also be discussed with the patient and documented in the medical record ^(15,16)

• Active infection (local or remote). If a local or remote infection is documented in the patient’s history, records should clearly demonstrate that the previous infection has been treated and symptoms have resolved or that the individual has no clinical signs or symptoms of the previous infection at the time of the operation ⁽²⁾

• Any corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}
• Any prior arthroscopic knee surgery within 6 months of surgery ^(12,13,14)

• Prior infection at site (unless aspiration with cultures and serology [CBC with differential, ESR, CRP] demonstrates no infection). If prior infection at site, tissue biopsies should be sent intra-operatively to exclude latent/dormant infection
• Documented allergy to any proposed component
• BMI > 40 without discussion of increased risk ⁽¹⁾
• Severe peripheral vascular disease
• Compromised soft tissue envelope
• Uncontrolled comorbidities ⁽¹⁸⁾

Unicompartmental Knee Arthroplasty (UKA)/Partial Knee Replacement (PKA)
All requests for UKA in individuals with chronic, painless effusion and extensive radiographic arthritis will be evaluated on a case-by-case basis.

Medial or lateral UKA/PKA may be medically necessary when ALL of the following criteria are met ⁽¹⁹⁾:

• At least 12 weeks of pain localized to the medial or lateral compartment
• Unless bone-on-bone articulation is present, failure of at least 12 weeks of non-operative treatment, including at least TWO of the following ^(3,4):
  • Rest or activity modifications/limitations
  • Weight reduction for individual with elevated BMI
  • Protected weight-bearing with cane, walker, or crutches
  • Brace/orthosis
  • Physical therapy modalities
  • Physician-supervised exercise program (including home exercise program)
  • Application of heat or ice
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
  • Injections: corticosteroid or viscosupplementation
• Total arc of motion (goniometer) > 90 degrees
• Normal ACL or stable reconstructed ACL per physical exam test ^(20,21)
• Contracture ≤ 10 degrees upon physical exam (goniometer) ⁽²²⁾
• Angular deformity ≤ 10 degrees, passively correctable to neutral upon physical exam (goniometer)

• Weight-bearing radiographs demonstrate only unicompartmental disease (with or without patellofemoral involvement), described as Kellgren-Lawrence grade 3 or grade 4 degeneration

NOTE: MRI should not be the primary radiographic test used to determine the presence or severity of arthritic changes in the joint ⁽⁷⁾

• No corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}
• No prior arthroscopic knee surgery within 6 months of surgery ^{(12,13,14,23)}
• ALL requests for simultaneous bilateral partial knee replacements should clearly indicate why simultaneous UKA is preferable to staged procedures. Associated risks with simultaneous bilateral partial knee replacements should also be discussed with the patient and documented in the medical record ^(15,16)

• Any corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}
• Any prior arthroscopic knee surgery within 6 months of surgery ^(12,13,14)
• Local or systemic active infection
• Inflammatory arthritis
• Angular deformity or contracture greater than indicated range
• Significant arthritic involvement of opposite compartment
• ACL instability
• Poor bone quality or significant osteoporosis or osteopenia
• Meniscectomy of the opposite compartment, involving > 25% of meniscus
• Stiffness greater than indicated range of motion

May be medically necessary when ALL of the criteria are met within ONE of the following two sections:

• Section One ^(24,25):
  • Failure of prior patellofemoral unloading procedures (i.e., Maquet or Fulkerson)
  • Unless patellofemoral bone-on-bone articulation is present, failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Weight reduction for individual with elevated BMI
    • Protected weight-bearing with cane, walker, or crutches
    • Brace/orthosis
    • Physical therapy modalities
    • Physician-supervised exercise program (including home exercise program)

• • • Application of heat or ice

• • • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
    • Injections: corticosteroid or viscosupplementation
  • Standing, AP, or PA weight-bearing x-rays demonstrate only unicompartmental disease of the patellofemoral joint, described as Kellgren-Lawrence grade 3 or grade 4 degeneration (joint space narrowing, osteophyte formation, sclerosis and/or subchondral cystic changes), with no evidence of medial or lateral compartment arthritis.
• Section Two ^(24,25):
  • At least 6 months of isolated patellar/anterior knee pain
  • Patellar/anterior knee pain that is exacerbated by stairs, inclines, transfers, or prolonged sitting
  • Reproducible patellofemoral pain upon physical exam 
  • No ligamentous instability upon physical exam
  • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Weight reduction for individual with elevated BMI
    • Protected weight-bearing with cane, walker, or crutches
    • Brace/orthosis
    • Physical therapy modalities
    • Physician-supervised exercise program (including home exercise program)
    • Application of heat or ice
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
    • Injections: corticosteroid or viscosupplementation
  • Standing, AP, or PA weight-bearing radiographs demonstrate only unicompartmental disease of the patellofemoral joint, described as Kellgren-Lawrence grade 3 or grade 4 degeneration, with no evidence of medial or lateral compartment arthritis
  • No cortisone injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}

NOTE: MRI should not be the primary radiographic test used to determine the presence or severity of arthritic changes in the joint ⁽⁷⁾

• Any corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}
• Local or systemic active infection
• Inflammatory arthritis
• Angular deformity or contracture greater than indicated range
• Significant arthritic involvement of the medial or lateral knee compartment(s)
• Ligament instability

• Poor bone quality or significant osteoporosis or osteopenia
• Stiffness greater than indicated range of motion

Revision TKA may be considered medically necessary when the following criteria in either section one or section two are met ^(23,26):

• Section One
  • Previous removal of infected knee prosthesis
  • No evidence of current, ongoing, or inadequately treated knee infection (ruled out by normal inflammatory markers (ESR and CRP) or significant improvement in these markers. If these inflammatory markers are elevated, further evaluation is required, including an aspiration with synovial fluid WBC count, gram stain and cultures, or an intraoperative frozen biopsy.
  • A clear statement by the treating surgeon that infection has been adequately treated)
  • Patient is off antibiotics
• Section Two
  • When ALL of the following criteria are met:
    • Symptomatic UKA/PKA or TKA as evidenced by persistent, severe, disabling pain, complaints of instability, mechanical abnormalities ('clunking' or audible crepitus), any of which result in a loss of function
    • Any of the following findings upon physical exam: tenderness to palpation objectively attributable to the implant, swelling or effusion, pain on weight-bearing or motion, instability on stress-testing, abnormal or limited motion (compared to usual function), palpable or audible crepitus or 'clunking' associated with reproducible pain
    • Aseptic loosening, instability, osteolysis, progressive bone loss, or mechanical failure confirmed on radiographic or advanced imaging (bone scan, CT scan, or MRI)
    • For implant loosening seen on routine X-rays or advanced imaging, documentation of no current, ongoing, or inadequately treated knee infection, ruled out by normal inflammatory markers (ESR and CRP). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection.
    • If the revision is for obvious radiographic evidence of hardware failure or there is a history of instability, inflammatory markers are not required
    • Cases that do not demonstrate any radiographic abnormalities yet show findings of gross instability on physical examination will be evaluated on a case-by-case basis
  • No corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}

Prosthesis Removal

• Removal of infected knee prosthesis and subsequent insertion of antibiotic spacer is not considered a revision knee arthroplasty

Absolute Contraindication

• Active infection (local or remote). If a local or remote infection is documented in the patient’s history, records should clearly demonstrate that the previous infection has been treated and symptoms have resolved or that the individual has no clinical signs or symptoms of the previous infection at the time of the operation
• Any corticosteroid injection into the joint within 12 weeks of surgery ^{(1,8,9,10,11)}

• Unstable or poorly controlled comorbidities
• Severe peripheral vascular disease
• Compromised soft-tissue envelope (revision may be performed in conjunction with plastic surgical consultation for soft tissue coverage via pedicle flaps or other acceptable procedure)

• Manipulation following total knee arthroplasty:
  • See CAM 776 Knee Arthroscopy for specific Manipulation indications

References

1. Hannon C, Goodman S, Austin M, Yates A, Guyatt G et al. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Care and Research. 2023; 75: 2227-2238. 10.1002/acr.25175.

2. Hsu H, Siwiec R M. Knee Arthroplasty [2023 Jul 24]. Stat Pearls Publishing. 2023; Accessed: 9/18/2024. https://www.ncbi.nlm.nih.gov/books/NBK507914/.

3. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline. American Academy of Orthopaedic Surgeons. 2021;

4. Kolasinski S L, Neogi T, Hochberg M C, Oatis C, Guyatt G et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care and Research. 2020; 72: 149-162. 10.1002/acr.24131.

5. Wilson C, Marappa-Ganeshan R. Secondary Osteonecrosis of the Knee [Updated 2023 Jul 24]. Stat Pearls Publishing. 2023; Accessed: 09/16/2024. https://www.ncbi.nlm.nih.gov/books/NBK562286/.

6. Rehman Y, Lindberg M, Arnljot K, Gay C, Lerdal A. More Severe Radiographic Osteoarthritis Is Associated With Increased Improvement in Patients’ Health State Following a Total Knee Arthroplasty. Journal of Arthroplasty. 2020; 35: 3131-3137. 10.1016/j.arth.2020.06.025.

7. Newman S, Ahmed H, Rehmatullah N. Radiographic vs. MRI vs. arthroscopic assessment and grading of knee osteoarthritis - are we using appropriate imaging? Journal of Experimental Orthopaedics. 2022; 9: 10.1186/s40634-021-00442-y.

8. Baums M, Aquilina J, Pérez-Prieto D, Sleiman O, Geropoulos G. Risk analysis of periprosthetic knee joint infection (PJI) in total knee arthroplasty after preoperative corticosteroid injection: a systematic review : A study performed by the Early-Osteoarthritis group of ESSKA-European Knee Associates section. Archives of orthopaedic and trauma surgery. 2023; 143: 2683-2691. 10.1007/s00402-022-04532-z.

9. Cancienne J, Werner B, Luetkemeyer L, Browne J. Does Timing of Previous Intra-Articular Steroid Injection Affect the Post-Operative Rate of Infection in Total Knee Arthroplasty? Journal of Arthroplasty. 2015; 30: 1879-1882. 10.1016/j.arth.2015.05.027.

10. Kim Y, Joo Y, Song J. Preoperative intra-articular steroid injections within 3 months increase the risk of periprosthetic joint infection in total knee arthroplasty: a systematic review and meta-analysis. Journal of orthopaedic surgery and research. 2023; 18: 148. 10.1186/s13018-023-03637-4.

11. Lai Q, Cai K, Lin T, Zhou C, Chen Z. Prior Intra-articular Corticosteroid Injection Within 3 Months May Increase the Risk of Deep Infection in Subsequent Joint Arthroplasty: A Meta-analysis. Clinical Orthopaedics and Related Research. 2022; 480: 971-979. 10.1097/CORR.0000000000002055.

12. Liu Q, Tian Z, Pian K, Duan H, Wang Q et al. The influence of prior arthroscopy on outcomes of primary total lower extremity arthroplasty: A systematic review and meta-analysis. International Journal of Surgery. 2022; 98: 10.1016/j.ijsu. 2021.106218 .

13. Goyal T, Tripathy S, Schuh A, Paul S. Total knee arthroplasty after a prior knee arthroscopy has higher complication rates: a systematic review. Archives of orthopaedic and trauma surgery. 2022; 142: 3415-3425. 10.1007/s00402-021-04175-6.

14. Ma J, Li X, Liang P, Yu S. When can total knee arthroplasty be safely performed following prior arthroscopy? BMC Musculoskeletal Disorders. 2021; 22: 10.1186/s12891-020-03859-1.

15. Liu L, Liu H, Zhang H, Song J, Zhang L. Bilateral total knee arthroplasty Simultaneous or staged? A systematic review and meta-analysis. Medicine (United States). 2019; 98: 10.1097/MD.0000000000015931.

16. Richardson M, Liu K, Mayfield C, Kistler N, Christ A. Complications and Safety of Simultaneous Bilateral Total Knee Arthroplasty: A Patient Characteristic and Comorbidity-Matched Analysis. Journal of Bone and Joint Surgery. 2023; 105: 1072-1079. 10.2106/JBJS.23.00112.

17. Varacallo M, Luo T D, Mabrouk A, Johanson N A. Total Knee Arthroplasty Techniques [Updated 2024 May]. Stat Pearls Publishing. 2024; Accessed: 09/16/2024. https://www.ncbi.nlm.nih.gov/books/NBK499896/.

18. Dooley P, Secretan C. Total knee replacement: Understanding patient-related factors. BC Medical Journal. 2016; 58: 514-519.

19. Luo T D, Hubbard J B. Arthroplasty Knee Unicompartmental. Stat Pearls Publishing. 2023; Accessed: 09/16/2024. https://www.ncbi.nlm.nih.gov/books/NBK538267/.

20. Jaber A, Kim C, Barié A, Streit M, Schmitt H et al. Combined treatment with medial unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction is effective on long-term follow-up. Knee Surgery, Sports Traumatology, Arthroscopy. 2023; 31: 1382-1387. 10.1007/s00167-022-07102-3.

21. Mancuso F, Dodd C, Murray D, Pandit H. Medial unicompartmental knee arthroplasty in the ACL-deficient knee. Journal of Orthopaedics and Traumatology. 2016; 17: 267-275. 10.1007/s10195-016-0402-2.

22. Purcell R, Cody J, Ammeen D, Goyal N, Engh G. Elimination of Preoperative Flexion Contracture as a Contraindication for Unicompartmental Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2018; 26: e158-e163. 10.5435/JAAOS-D-16-00802.

23. Ayoade F, Li D D, Mabrouk A, Todd J R. Periprosthetic Joint Infection [Updated 2023 Oct 14]. Stat Pearls Publishing. 2023; Accessed: 09/16/2024. https://www.ncbi.nlm.nih.gov/books/NBK448131/.

24. Pisanu G, Rosso F, Bertolo C, Dettoni F, Blonna D et al. Patellofemoral arthroplasty: Current concepts and review of the literature. Joints. 2017; 5: 237-245. 10.1055/s-0037-1606618.

25. Vasso M, Antoniadis A, Helmy N. Update on unicompartmental knee arthroplasty: Current indications and failure modes. EFORT Open Reviews. 2018; 3: 442-448. 10.1302/2058-5241.3.170060.

26. Salari P, Baldini A. Revision knee surgery: the practical approach. EFORT Open Reviews. 2021; 6: 495-500. 10.1302/2058-5241.6.210018.

27. Washington State Health Care Authority. Total Knee Arthroplasty [Adopted December 10, 2010]. Washington State Health Care Authority. 2010; Accessed: 09/18/2024. https://www.hca.wa.gov/assets/program/findings_decision_tka_121010[1]_0.pdf.

28. Kellgren J, Lawrence J. Radiological Assessment of Osteo-Arthrosis. Annals of the Rheumatic Diseases. 1957; 16: 494-502. 10.1136/ard.16.4.494

BACKGROUND
Grading Appendix
Kellgren-Lawrence Grading System (Standing/weight-bearing X-rays) ⁽²⁸⁾

Grade	Description
0	No radiographic features of osteoarthritis
1	Possible joint space narrowing and osteophyte formation
2	Definite osteophyte formation with possible joint space narrowing
3	Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour (some sclerosis and cyst formation)
4	Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour.

Coding Section

Code	Number	Description
CPT	27438	Arthroplasty, patella; with prosthesis
	27446	Arthroplasty, knee, condyle and plateau; medial or lateral compartment
	27447	Arthroplasty, knee, condyle and plateau; medial or lateral compartments with or without patella resurfacing (total knee arthroplasty)
	27486	Revision of total knee arthroplasty, with or without allograft; 1 component
	27487	Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2026 Forward

04/01/2026

NEW POLICY