CommercialCoverageHigh impact
Metal-on-Metal Total Hip Resurfacing 7.01.74
Excellus BlueCross BlueShield·Orthopedics·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield has established new medical necessity criteria for metal-on-metal total hip resurfacing, effective October 15, 2025. The policy requires patients to be 64 years or younger, have specific imaging findings, experience function-limiting pain for at least 3 months, and fail non-surgical management for 3 months, with several specific contraindications listed.
Action Required
By October 15, 2025: Billing team must update prior authorization requirements for metal-on-metal total hip resurfacing procedures to ensure all four criteria are met: patient age 64 or younger, specific imaging findings (osteoarthritis affecting femoral head and acetabulum OR avascular necrosis with less than 50% femoral head involvement), function-limiting pain for 3+ months with loss of hip function, and failure of 3+ months non-surgical management. Providers must document all contraindications are absent and optimize patient comorbidities preoperatively. Update EMR templates to include required documentation elements.