Total Hip Arthroplasty (THA)
Summary
Total hip arthroplasty is considered medically necessary when all of the listed criteria are met, including a diagnosis of osteoarthritis, osteonecrosis, rheumatoid arthritis, bone tumor involving the hip or acute femoral neck fracture, radiographic hip joint damage, significant persistent pain and functional limitations, and failure of optimal medical management such as weight loss, NSAIDs, DMARDs, cortisone injections, physical therapy, walking aids and reduced physical activity. Revision THA of a failed hip prosthesis may be considered medically necessary when pain or swelling increases significantly or function decreases, in the presence of infection, wear and loosening, malalignment or malposition, fractures or instability. Ambulatory THA and revision THA in adults 18 and older also require ASA Physical Status 3 or less, a BMI of 50 or less, proactive treatment for possible MSSA or MRSA before surgery, the absence of the listed contraindications, and care coordination, and benefits are only provided when the procedure is performed by a Blue Specialty Network Provider in a setting coordinated and contracted with the Company.
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