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Billing codes
27091

PAYER POLICY CHANGES

27091 Insurance Policy Changes

CPT 27091, in plain terms, covers Surgeon removes a complicated hip prosthesis, including a total hip implant, along with cement, and may place an antibiotic spacer. CPT 27091 is referenced in 4 tracked payer policy changes from Excellus BlueCross BlueShield and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 27091 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 27091 on AAPC

Excellus BlueCross BlueShield · Effective Jan 1, 2027Medium impact
Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121
Excellus BlueCross BlueShield medical policy 7.01.121 covers hip joint procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) members, with a current effective date of January 1, 2027. The policy sets medical necessity criteria for partial and total hip arthroplasty, revision hip arthroplasty, hip resurfacing, pediatric osteotomy, hip arthroscopy, and hip labral repair, and it lists indications that are not medically necessary. The policy history lists a 09/17/26 new policy and a 10/22/26 off-cycle review that removed site of care criteria and clarified developmental hip dysplasia and primary cause of surgery.
Excellus BlueCross BlueShield · Effective Jan 1, 2027Medium impact
Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121
Excellus BlueCross BlueShield medical policy 7.01.121 sets the medical necessity criteria for hip joint procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) members. The current effective date is January 1, 2027. The policy covers partial and total hip arthroplasty, hip resurfacing, pediatric pelvic or femoral osteotomy for developmental dysplasia of the hip, hip arthroscopy, and hip labral repair, and it lists indications that are not medically necessary. The policy history shows a 10/22/26 off-cycle review that removed site of care criteria, clarified developmental hip dysplasia and primary cause of surgery, removed imaging requirements for pediatric osteotomy patients, and reformatted age-appropriate clinical findings.
Aetna · Identified Oct 3, 2026Medium impact
Hip Arthroplasty (CPB 0287, reviewed 2026-09-23)
Aetna Clinical Policy Bulletin 0287 sets medical necessity criteria for total hip arthroplasty (THA) and for revision or replacement of a THA or hip resurfacing. A primary THA is considered medically necessary for adult members with advanced hip joint disease from osteoarthritis, rheumatoid arthritis, avascular necrosis or post-traumatic arthritis that causes pain and functional disability interfering with activities of daily living, with limited range of motion, antalgic gait and pain on passive range of motion, plus imaging showing stage II or III avascular necrosis or moderate or severe osteoarthritis or rheumatoid arthritis (Tonnis grade 2 or 3), after unsuccessful conservative therapy of 12 or 24 weeks depending on age and BMI, with at least half of it formal in-person physical therapy in the past year. Revision or replacement is considered medically necessary when accompanied by pain and functional disability and imaging confirms aseptic loosening, component fracture or mechanical failure, periprosthetic infection, displaced periprosthetic fracture, progressive periprosthetic bone loss, bearing surface wear with symptomatic synovitis, or recurrent dislocation, and the policy lists computer-assisted surgical navigation, portable accelerometer-based navigation, synovial C-reactive protein and alpha-defensin testing, and obturator nerve blocks among experimental, investigational or unproven services.
Aetna · Identified Aug 16, 2026Medium impact
Hip Arthroplasty (CPB 0287, reviewed 2026-07-17)
Total hip arthroplasty is considered medically necessary for adult members when an FDA-approved implant is used and the member has advanced joint disease, meaning pain and functional disability that interferes with activities of daily living from osteoarthritis, rheumatoid arthritis, avascular necrosis or post-traumatic arthritis, along with limited range of motion, antalgic gait and radiographic evidence of avascular necrosis stage II or III or moderate/severe osteoarthritis or rheumatoid arthritis of the hip. Unsuccessful conservative therapy of 12 or 24 weeks, depending on age and BMI, must be clearly addressed in the medical record, with at least half consisting of formal in-person physical therapy in the past year. Revision or replacement of a total hip arthroplasty or hip resurfacing is covered when imaging confirms an indication such as aseptic loosening, component fracture or mechanical failure, periprosthetic infection, displaced periprosthetic fracture, progressive bone loss, bearing surface wear, recurrent dislocation or clinically significant leg length discrepancy. Computer-assisted navigation, custom joint implants, synovial CRP and alpha-defensin testing, obturator nerve blocks and portable accelerometer-based navigation are listed as experimental, investigational or unproven.

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REFERENCE DATA

Payers with rules7

Payers requiring prior auth7

Aetna · Effective November 1, 2026
Prior authorization required
Participating provider precertification list for Aetna
BCBS Michigan · Effective October 13, 2026
Prior authorization required in some cases
BCBSM and BCN procedure codes for which providers must request prior authorization (commercial lines)
Ambetter · Effective December 31, 2025
Prior authorization required
Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does Aetna require prior authorization for 27091?

Aetna lists 27091 on Participating provider precertification list for Aetna for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Ambetter require prior authorization for 27091?

Ambetter lists 27091 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Arizona Complete Health require prior authorization for 27091?

Arizona Complete Health lists 27091 on Arizona Complete Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does BCBS Michigan require prior authorization for 27091?

BCBS Michigan lists 27091 on BCBSM and BCN procedure codes for which providers must request prior authorization (commercial lines) for commercial plans, with conditions (list dated October 13, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for 27091?

CalViva Health lists 27091 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 27091?

There are 4 tracked policy changes affecting CPT 27091, including updates from Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 27091?

Payers that have issued tracked updates for CPT 27091 include: Excellus BlueCross BlueShield, Aetna.

How do I get notified when CPT 27091 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 27091. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 27091?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 27091 in one place.

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Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121