CommercialPrior AuthHigh impact
Knee Arthroplasty (CPB 0660, reviewed 2026-02-26)
Aetna·Orthopedics, General Surgery, Sports Medicine·Surgery
Effective date
Feb 26, 2026
We identified it
Aug 18, 2026
Summary
Aetna has updated its Clinical Policy Bulletin 0660 for knee arthroplasty procedures, effective immediately. This policy establishes comprehensive medical necessity criteria for total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and revision procedures, including specific requirements for conservative therapy documentation, physical therapy evidence, and contraindication screening. Billing teams must ensure all knee arthroplasty claims include complete documentation of radiographic findings (Kellgren-Lawrence grading), at least 12-24 weeks of conservative therapy with formal PT notes, and verification that absolute contraindications are absent.
Action Required
Effective immediately (2026-02-26): Billing team must update prior authorization workflows and medical necessity review processes for all knee arthroplasty claims (CPT 27447-27458, 27486) to enforce Aetna's updated criteria. SPECIFIC ACTIONS: (1) Modify claim submission checklist to require documentation of: Kellgren-Lawrence Grade 3-4 radiographic findings; 12 weeks minimum conservative therapy (24 weeks for BMI >40 or age <50); formal in-person physical therapy notes from licensed PT (minimum 50% of conservative therapy period); anti-inflammatory medications/analgesics trial; flexibility/strengthening exercises; activity modification; assistive device use and therapeutic knee injections (if relative contraindications present). (2) Update authorization request forms to screen for absolute contraindications: active joint/systemic infection, active skin infection/open wound at surgical site, corticosteroid injection within 12 weeks, vascular insufficiency, neuromuscular disease, inadequate bone stock, implant allergies. (3) For unicompartmental cases, add requirement verification: intact/stable ligaments (especially ACL), knee arc motion >90 degrees, single compartment disease only, no prior osteotomy, no deformity exceeding limits (varus >15°, valgus >20°). (4) Implement revision surgery criteria requiring imaging confirmation of: aseptic loosening, prosthetic fracture/wear, periprosthetic infection with culture, periprosthetic fracture, bone loss, bearing surface wear, malalignment >15°, arthrofibrosis, instability, or extensor mechanism problems. (5) Train providers and office staff on documentation requirements during claim preparation. (6) Update EMR templates and encounter forms to prompt providers to address conservative therapy details and document why conservative therapy is inappropriate (if applicable). RESPONSIBLE PARTIES: Billing team performs system updates; providers must enhance documentation; front desk staff ensure complete records at time of submission. CONSEQUENCES: Claims lacking required documentation or failing to meet medical necessity criteria will be denied by Aetna, resulting in claim rework, delayed payment, and potential patient liability.