Blue Cross & Blue Shield of MississippiAll Plans · Prior Auth · Medical Policy · MS · OrthopedicsMedium impact
Total Hip Arthroplasty (THA) - West Central and North East Region
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Total hip arthroplasty (THA) is considered medically necessary when all criteria are met, including a diagnosis of osteoarthritis, osteonecrosis, rheumatoid arthritis, bone tumor involving the hip, or acute femoral neck fracture, radiographic evidence of hip joint damage, significant persistent pain and functional limitations, and optimal medical management tried and failed. The Company requires care coordination for all hip arthroplasty Specialty Services, and hospital hip arthroplasty is covered only when hospital criteria are met and care is coordinated by the Company. This policy applies to Network Providers in the West Central and North East Regions of Mississippi only.
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01Billing team: Hospital hip arthroplasty, including revision arthroplasty, is considered medically necessary in adults 18 and older who meet the medical necessity criteria and one or more hospital criteria, such as ASA Physical Status 4 or more, BMI 50 or more subject to physician discretion, pregnancy, expected operative time over 120 minutes, or hemoglobin below 12 or other anticipated need for blood transfusion.
02Benefits for hospital hip arthroplasty are provided only when hospital setting criteria are met and care is coordinated by the Company.
03Benefits for other hip arthroplasty Specialty Services are provided when services are rendered by a Blue Specialty Network Provider in a setting coordinated and contracted with the Company.
04For State Health Plan members, all inpatient hospital admissions for total hip arthroplasty must be certified as medically necessary by the State Health Plan's Utilization Review Vendor.
05This policy does not apply to inpatient hospital admissions for total hip arthroplasty performed and submitted under the BlueCard Program for Members of other Plans.
Codes mentioned
2713027132271342713727138
Original notice
Total Hip Arthroplasty (THA) - West Central and North East Region
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