CommercialPrior AuthHigh impact
Hip Arthroplasty (CPB 0287, reviewed 2026-07-17)
Aetna·Orthopedics, General Surgery·Surgery
Effective date
Jul 17, 2026
We identified it
Aug 16, 2026
Summary
Aetna's Hip Arthroplasty policy (CPB 0287) establishes comprehensive medical necessity criteria for total hip arthroplasty (THA), revisions, and related procedures. Key requirements include documentation of advanced joint disease, failed conservative therapy (minimum 12-24 weeks with in-person physical therapy), imaging confirmation, and specific contraindication assessments. Several procedures including computer-assisted navigation, custom implants, and AR/VR assistance are classified as experimental and not covered.
Action Required
By 2026-07-17: Billing team and providers must implement the following changes: (1) Update claim submission workflows to require documentation of failed conservative therapy with minimum 12 weeks (or 24 weeks for BMI >40 or age <50) of non-surgical treatment including in-person physical therapy notes before authorizing THA; (2) Implement precertification process by using Aetna's CPT code search tool to identify procedures requiring prior authorization; (3) Update encounter forms and EMR templates to require providers to document advanced joint disease (pain/functional disability in ADLs), ROM limitations, and radiographic evidence (Tonnis grade 2-3 osteoarthritis or stage II-III avascular necrosis) before surgery; (4) Configure billing system to flag and deny claims for experimental procedures: computer-assisted navigation (MAKOplasty), AR/VR assistance, custom implants/instrumentation, synovial C-reactive protein testing, alpha-defensin test (Synovasure), obturator nerve blocks, and accelerometer-based navigation; (5) For diabetic members, ensure HbA1c <8% within 3 months prior to surgery is documented; (6) Educate providers that revision THA requires specific indications (aseptic loosening, mechanical failure, confirmed periprosthetic infection via gram stain/culture, bearing surface wear with synovitis, or recurrent dislocations) with imaging confirmation; (7) Verify absolute contraindications are addressed in medical record (active infection, allergy to implant components, corticosteroid injection within 12 weeks, paraplegia/quadriplegia, skeletal immaturity); (8) Flag claims missing required documentation for denial. Failure to comply will result in claim denials and potential member grievances.