Medicare AdvantageCoverageHigh impact
Knee Arthroplasty - Medicare Advantage (Revised)
Humana·Orthopedics, General Surgery·Medicare Advantage
Effective date
Mar 16, 2026
We identified it
Jun 24, 2026
Summary
This is a new Medicare Advantage medical coverage policy for knee arthroplasty procedures that establishes detailed coverage criteria for unicompartmental knee arthroplasty, including requirements for conservative treatment failure, radiographic confirmation, and absence of contraindications. The policy provides comprehensive guidelines for when knee replacement procedures will be considered medically necessary.
Action Required
Before March 16, 2026: Billing team must update prior authorization procedures for knee arthroplasty CPT codes to ensure documentation includes conservative treatment failure, radiographic confirmation of joint pathology (Outerbridge Grade 4 or Kellgren Lawrence Grade 4), and absence of contraindications. Providers must document painful, disabling joint disease interfering with ADLs and appropriate conservative treatments attempted. Update EMR templates to include required documentation elements for Medicare Advantage knee arthroplasty claims.