Total knee or hip joint replacement
Applies to:
- All plans
- Medicare plans follow Medicare coverage and billing rules
Medical policy
Total Joint Replacement: Knee, Shoulder & Hip - 91630Joint replacement authorizations
Participating surgeons and facilities should use the online Auth Request tool to enter procedure codes and request authorization for total hip and total knee replacement.
Non-participating providers should use our authorization forms.
Post-surgical therapy authorizations
Post-surgical therapy in a sub-acute rehab facility requires prior authorization. Approval is subject to medical criteria and based on the patient's needs at the time of hospitalization and discharge. Examples:
- If a patient is walking several feet with an aide, the appropriate next level of care would be outpatient or in-home therapy.
- Patients who are older with multiple co-morbidities and who have caregivers who are unable to provide assistance may need a brief stay in a sub-acute rehab facility.
Authorization tools
In prism, you can request a new authorization or check an auth's status.