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Metal-on-Metal Total Hip Resurfacing - (Effective Date - 2026-10-15) 7.01.74
Excellus BlueCross BlueShield·NY · Orthopedics·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has issued a new medical policy (7.01.74, effective October 15, 2026) establishing coverage criteria for metal-on-metal total hip resurfacing in patients age 64 and younger. The policy requires strict documentation of medical necessity, including imaging findings, function-limiting symptoms lasting 3+ months, failed conservative management, and excludes patients with specific contraindications (metal sensitivity, childbearing potential, dialysis patients, >50% femoral head involvement, and others). Billing teams must implement prior authorization requirements and documentation validation before claims submission.
Action Required
By October 15, 2026: Billing and prior authorization teams must implement the following:
1. UPDATE AUTHORIZATION SYSTEM: Configure prior authorization requirements for metal-on-metal total hip resurfacing procedures. Flag all requests for age verification (must be ≤64 years old).
2. PROVIDER DOCUMENTATION REQUIREMENTS: Communicate with orthopedic surgeons and providers that claims MUST include: (a) Weight-bearing radiographs showing osteoarthritis/inflammatory arthritis OR avascular necrosis with <50% femoral head involvement; (b) Documentation of function-limiting pain at short distances (<¼ mile) for ≥3 months OR documented exception reason (collapse, inflammatory arthritis, advanced dysplasia); (c) Evidence of failed provider-directed non-surgical management for ≥3 months OR documented exception reason; (d) Documentation that patient has loss of hip function interfering with age-appropriate activities of daily living.
3. CONTRAINDICATION SCREENING CHECKLIST: Create pre-authorization checklist to verify patient does NOT have: active infection, vascular insufficiency, Charcot joint, dialysis/renal transplant list status, inadequate bone stock, severe overweight status, immunosuppression/high-dose corticosteroids, known/suspected metal sensitivity, or childbearing potential. DENY coverage if any contraindication present.
4. CLAIM DENIAL PROTOCOL: Any claims submitted without required documentation or with patients meeting contraindication criteria will be DENIED. Establish communication pathway to notify providers of documentation gaps requiring resubmission.
5. BILLING SOFTWARE UPDATE: Ensure EMR/billing system templates include fields for all required supporting documentation. Update claim submission workflows to prevent submission until all criteria are verified.
6. STAFF TRAINING: Before October 15, 2026, train all billing and authorization staff on the 5-criterion requirement and 10 contraindications listed in Section II. Non-compliance will result in claim denials and potential audit liability.
RESPONSIBLE PARTIES: Prior Authorization Department (authorization configuration), Billing Team (documentation validation), Providers (medical record documentation), Front Desk/Intake Staff (age verification at scheduling).