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27125

PAYER POLICY CHANGES

27125 Insurance Policy Changes

CPT 27125, in plain terms, covers Surgeon replaces the ball of the hip with a prosthesis, such as after a fracture, while the patient's own socket is kept. CPT 27125 is referenced in 14 tracked payer policy changes from Excellus BlueCross BlueShield, Humana, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 27125 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 27125 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.
Humana · Effective Mar 16, 2026High impact
Hip Arthroplasty - Medicare Advantage (Revised)
This is a revised Medicare Advantage policy for hip arthroplasty procedures that establishes detailed coverage criteria for total hip replacement, partial hip replacement (hemiarthroplasty), and hip resurfacing procedures. The policy provides specific medical necessity requirements and contraindications for each type of hip surgery.
Premera Blue Cross · Effective Jan 2, 2026High impact
Medical Policy and Coding Updates - October 2025
Premera HMO plans in Washington have changes from the October 2025 medical policy and coding update. Dated items include the Abdominal Wall Hernia policy and its codes effective January 2, 2026, advanced imaging site-of-care review through Carelon and a Washington mandate for medical clearance of minors' hearing aid coverage effective January 1, 2026, and Federal Employee Program prior authorization for hip, knee and spine surgery effective January 1, 2026. Several biologic and drug policies also moved products between preferred and non-preferred status.
Blue Cross Blue Shield of Wyoming · Effective Jan 1, 2026High impact
Enhancing Provider Support During Open Enrollment
Starting January 1, 2026, Federal Employee Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) Standard or Basic Option plans will require prior authorization for all hip, knee, and spine surgeries. Blue Cross Blue Shield Wyoming has also expanded their provider service team during open enrollment to handle increased call volumes.
BCBS Michigan · Effective Jan 1, 2026High impact
Select musculoskeletal procedure codes continue to require prior authorization through e-referral for FEP members, won’t move to TurningPoint
For Blue Cross Blue Shield Federal Employee Program (FEP) members with commercial plans, prior authorization continues to be required through e-referral for select musculoskeletal procedures including hip, knee, and spinal surgeries effective January 1, 2026. These procedures will NOT move to TurningPoint Healthcare Solutions as previously announced.
Premera Blue Cross · Identified Jun 16, 2026High impact
Medical Policy and Coding Updates - December 2025
With effective dates from December 1, 2025 through March 4, 2026. The update adds medical necessity and prior authorization review for electrophysiology studies, endovascular stent grafts for abdominal aortic aneurysms, shoulder arthrotomy, gastroesophageal reflux surgery, negative pressure wound therapy devices, and hip, knee and spine surgeries for Standard and Basic Federal Employee Program plans effective January 1, 2026. Several codes were made non-covered or investigational, including the services listed under policy 10.01.517 and transcatheter tricuspid valve procedures.
Premera Blue Cross · Identified Jun 16, 2026High impact
Medical Policy and Coding Updates - January 2026
With effective dates from January 1, 2026 through April 8, 2026. The update adds medical necessity and prior authorization review for electrophysiology studies, endovascular stent grafts for abdominal aortic aneurysms, shoulder arthrotomy, shoulder arthroscopy, abdominal wall hernia repair, and hip, knee and spine surgeries for Standard and Basic Federal Employee Program plans, and it expands site of service ASC review to upper GI endoscopy and shoulder procedures. It also changes many drug criteria, including preferred product and quantity limit updates, adds Carelon review for advanced imaging, and lists codes that became non-covered, investigational or terminated.
Humana · Effective Nov 2, 2026Medium impact
Hip Arthroplasty - Medicare Advantage (Revised)
Humana Medicare Advantage revised its Hip Arthroplasty coverage policy effective 11/02/2026, updating medical necessity criteria for partial hip arthroplasty (hemiarthroplasty) and hip resurfacing arthroplasty across all jurisdictions. The policy specifies FDA-approved device requirements, patient age thresholds, preoperative A1C limits, and conservative treatment failure documentation for coverage determination.
Excellus BlueCross BlueShield · Effective Oct 15, 2026Medium impact
Hip Arthroplasty - (Effective Date - 2026-10-15) 7.01.96
Excellus's hip arthroplasty policy, effective October 15, 2026, covers partial and total hip replacement for femoral head or neck fracture, avascular necrosis, osteoarthritis, and inflammatory arthritis when the listed criteria are met. Revision of hip replacement is medically necessary for listed post-operative conditions such as recurrent dislocation, aseptic loosening, periprosthetic joint infection, and periprosthetic fracture. The 06/18/26 annual review left the policy intent unchanged, and a 10/16/25 change removed the renal transplant list from the total hip not medically necessary indications.
Aetna · Identified Oct 11, 2026Medium impact
Joint Resurfacing (CPB 0661, reviewed 2026-10-07)
Metal-on-metal hip resurfacing with an FDA-approved device is considered medically necessary as an alternative to total hip arthroplasty for physically active members under 65 who have advanced hip joint disease from osteoarthritis, avascular necrosis or post-traumatic arthritis and meet the listed criteria. Members should have at least 12 weeks of documented non-surgical treatment, unless contraindicated. Hip resurfacing is considered not medically necessary with contraindications such as active joint infection, metal allergy, morbid obesity (BMI greater than 40) and females of child-bearing age, and shoulder, knee, patellar, wrist, facet joint, toe joint and other listed resurfacing procedures are considered experimental, investigational or unproven.
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
Joint Resurfacing (CPB 0661, reviewed 2025-12-19)
Aetna considers metal-on-metal hip resurfacing with an FDA-approved device a medically necessary alternative to total hip arthroplasty for physically active non-elderly adult members under 65 who meet the listed criteria, and experimental, investigational, or unproven for all other indications. The policy also lists shoulder resurfacing, knee, partial knee and patellar resurfacing, wrist capitate resurfacing, metatarsophalangeal joint resurfacing, facet joint resurfacing, talar inlay resurfacing and navigation during hip resurfacing as experimental, investigational, or unproven. The policy history shows an original effective date of 05/02/2003 and a last review date of 10/07/2026.
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 rules20

Payers requiring prior auth20

Aetna · Effective November 1, 2026
Prior authorization required
Participating provider precertification list for Aetna
Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
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)

FREQUENTLY ASKED QUESTIONS

Does Aetna require prior authorization for 27125?

Aetna lists 27125 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 27125?

Ambetter lists 27125 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 Anthem BCBS require prior authorization for 27125?

Anthem BCBS lists 27125 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Arizona Complete Health require prior authorization for 27125?

Arizona Complete Health lists 27125 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 Arizona require prior authorization for 27125?

BCBS Arizona lists 27125 on AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Updated 10/01/2026) for medicare advantage plans (list dated October 1, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 27125?

There are 14 tracked policy changes affecting CPT 27125, including updates from Excellus BlueCross BlueShield, Humana, Premera Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 27125?

Payers that have issued tracked updates for CPT 27125 include: Excellus BlueCross BlueShield, Humana, Premera Blue Cross, Blue Cross Blue Shield of Wyoming, BCBS Michigan, Aetna.

How do I get notified when CPT 27125 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 27125. 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 27125?

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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All billing codes J3590 C9399 J3490 99215 99213 99202

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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

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

Hip Arthroplasty - Medicare Advantage (Revised)

Medical Policy and Coding Updates - October 2025

Enhancing Provider Support During Open Enrollment

Select musculoskeletal procedure codes continue to require prior authorization through e-referral for FEP members, won’t move to TurningPoint

Medical Policy and Coding Updates - December 2025

Medical Policy and Coding Updates - January 2026

Hip Arthroplasty - Medicare Advantage (Revised)

Hip Arthroplasty - (Effective Date - 2026-10-15) 7.01.96

Joint Resurfacing (CPB 0661, reviewed 2026-10-07)

Hip Arthroplasty (CPB 0287, reviewed 2026-09-23)

Joint Resurfacing (CPB 0661, reviewed 2025-12-19)

Hip Arthroplasty (CPB 0287, reviewed 2026-07-17)

Prior authorization required