Effective for services performed on Nov 1,2024 and there after, there will be new requirements for the prior authorization documentation applied to the Knee/Hip surgeries.
These changes/updates apply to self insured and fully insured plans nationwide.
Codes affected:
27445,27447, 27130 and 27132
Knee Surgery Documentstion requirenments:
- Complete diagnostic imaging Reports: -Documented closure of skeletal plates (age less than 18 years)
-Presence or absence of focal full-thickness articular cartilage defect
-Size and location of focal cartilage defect
-Outerbridge grade
-Joint space and alignment
-Ligament tear location and grade - Diagnostic Images: – show the abnormality- MRI, Xray, Bone scan.
- Prior treatment documentation (prior year): -NSAIDs or acetaminophen ≥ 3 weeks*
-PT or home exercise ≥ 12 weeks
-Activity modification ≥ 12 weeks
*For TJR Knee ≥ 1 intra-articular corticosteroid injection may be used in place of NSAIDs.
For more information please click visit: https://www.uhcprovider.com/en/resource-library/news/2024/documentation-requirement-updates-total-joint-replacements.html
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