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Hip Arthroplasty - (Effective Date - 2026-10-15) 7.01.96
Excellus BlueCross BlueShield·NY · Orthopedics, General Surgery·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has issued a new Hip Arthroplasty medical policy (7.01.96) effective October 15, 2026, establishing coverage criteria for partial hip replacement, total hip replacement, and revision procedures. The policy defines specific imaging findings, symptom requirements, and non-surgical management prerequisites that must be met for procedures to be considered medically necessary. Key exclusions include active infections, vascular insufficiency, dialysis patients, and inflammatory arthritis affecting both femoral head and acetabulum.
Action Required
By September 15, 2026 (30 days before effective date): Billing and clinical teams must review and implement the following changes: (1) Update prior authorization workflows in billing system to require documentation of imaging findings (Tönnis Grade 2-3 for OA, AVN with femoral head collapse, or inflammatory arthritis affecting both femoral head and acetabulum) before approving hip arthroplasty claims; (2) Create or update encounter templates for orthopedic surgeons to document: three months of function-limiting pain at short distances (less than one-quarter mile), loss of age-appropriate hip function, and three months of failed provider-directed non-surgical management (or medical record justification for why non-surgical management is inappropriate); (3) Implement system edits to flag and deny claims for patients with active infections, vascular insufficiency, significant muscular atrophy, neuromuscular disease, Charcot joints, or on dialysis; (4) Train billing staff on revision criteria (aseptic loosening, periprosthetic infection/fracture, instability, leg length discrepancy, osteolysis, elevated metal levels, or unexplained pain >6 months unresponsive to non-surgical management); (5) Update denial reason codes and communication templates to reference specific unmet criteria from this policy. Failure to implement these requirements will result in claim denials for procedures not meeting the documented medical necessity criteria.