Who is affected by this change?

This affects Excellus BlueCross BlueShield Orthopedics providers in NY on Medicaid plans.

When does this change take effect?

This change is effective Jan 1, 2027.

What do I need to do?

Starting January 1, 2027: Claims for total hip arthroplasty need documented BMI of 40 kg/m2 or less and one of the listed conditions, such as developmental dysplasia of the hip, a displaced or comminuted femoral neck or femoral head fracture, post-traumatic arthritis, or osteoarthritis with the listed arthritis type, pain, and conservative management. Conservative management for hip osteoarthritis must include physical therapy (supervised by a licensed PT, chiropractor, or through tele-rehab PT, for at least 6 weeks in the previous 6 months, with failure to improve) and pain management. Total hip arthroplasty is not medically necessary with nicotine or tobacco use within six weeks of surgery, or an intra-articular corticosteroid injection within 12 weeks of surgery. Claims for hip arthroscopy for femoroacetabular impingement need BMI of 40 kg/m2 or less and imaging that confirms CAM-type or pincer-type impingement. Claims for hip labral repair need an MRI that confirms an acetabular labral tear. The policy lists hip arthroscopy for bone marrow edema, radiographic or clinical evidence of fracture, and tear involving the abductor, adductor, or hamstring tendon complex as not medically necessary.

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Excellus BlueCross BlueShieldMedicaid · Coverage · Bone & Joints (Orthopedic) · NY · OrthopedicsMedium impact

Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121

Q: Which billing codes are affected?

The following codes are affected: 27033, 27050, 27070, 27071, 27090, 27091, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151, 27156, 27161, 27165, 27170, 27455, 29860, 29861, 29862, 29863, 29914, 29915, 29916, S2118, M05.051, M08.959, M12.551, M12.559, M16.0, M16.9, M80.051A, M80.059S, M80.851A, M80.859S, M84.451A, M84.453S, M84.459A, M84.459S, M84.551A, M84.559S, M84.651A, M84.659S, M84.750A, M84.759S, M87.050, M87.051, M87.059, M87.150, M87.151, M87.159, M87.250, M87.251, M87.256, M87.350, M87.351, M87.353, M87.850, M87.851, M87.859, M90.551, M90.559, M97.01XA, M97.02XS, S72.001A, S72.26XS.

Effective date

Jan 1, 2027

Identified

Oct 6, 2026

Summary

Excellus BlueCross BlueShield medical policy 7.01.121 sets the medical necessity criteria for hip joint procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) members. The current effective date is January 1, 2027. The policy covers partial and total hip arthroplasty, hip resurfacing, pediatric pelvic or femoral osteotomy for developmental dysplasia of the hip, hip arthroscopy, and hip labral repair, and it lists indications that are not medically necessary. The policy history shows a 10/22/26 off-cycle review that removed site of care criteria, clarified developmental hip dysplasia and primary cause of surgery, removed imaging requirements for pediatric osteotomy patients, and reformatted age-appropriate clinical findings.

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What to do

Action · 6 steps

01Starting January 1, 2027: Claims for total hip arthroplasty need documented BMI of 40 kg/m2 or less and one of the listed conditions, such as developmental dysplasia of the hip, a displaced or comminuted femoral neck or femoral head fracture, post-traumatic arthritis, or osteoarthritis with the listed arthritis type, pain, and conservative management.

02Conservative management for hip osteoarthritis must include physical therapy (supervised by a licensed PT, chiropractor, or through tele-rehab PT, for at least 6 weeks in the previous 6 months, with failure to improve) and pain management.

03Total hip arthroplasty is not medically necessary with nicotine or tobacco use within six weeks of surgery, or an intra-articular corticosteroid injection within 12 weeks of surgery.

04Claims for hip arthroscopy for femoroacetabular impingement need BMI of 40 kg/m2 or less and imaging that confirms CAM-type or pincer-type impingement.

05Claims for hip labral repair need an MRI that confirms an acetabular labral tear.

06The policy lists hip arthroscopy for bone marrow edema, radiographic or clinical evidence of fracture, and tear involving the abductor, adductor, or hamstring tendon complex as not medically necessary.

Codes mentioned

27033270502707027071270902709127125271302713227134271372713827140271462714727151271562716127165271702745529860298612986229863299142991529916S2118M05.051M08.959M12.551M12.559M16.0M16.9M80.051AM80.059SM80.851AM80.859SM84.451AM84.453SM84.459AM84.459SM84.551AM84.559SM84.651AM84.659SM84.750AM84.759SM87.050M87.051M87.059M87.150M87.151M87.159M87.250M87.251M87.256M87.350M87.351M87.353M87.850M87.851M87.859M90.551M90.559M97.01XAM97.02XSS72.001AS72.26XS

Original notice

Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121

excellusbcbs.com · Always check the source before changing claims.

View original ↗

Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121MediumEffective Jan 1, 2027 · Bone & Joints (Orthopedic)Hip Arthroplasty 7.01.96HighEffective Feb 16, 2026 · Bone & Joints (Orthopedic)Hip Arthroplasty - (Effective Date - 2026-10-15) 7.01.96MediumEffective Oct 15, 2026 · Bone & Joints (Orthopedic)Orthopedic Joint Procedures of the Knee for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.123MediumEffective Jan 1, 2027 · Bone & Joints (Orthopedic)Browse every Excellus BlueCross BlueShield change in the policy list

Related policy hubs

Excellus BlueCross BlueShield policies NY policy changes Orthopedics Code 27033 Code 27050 Code 27070 Code 27071 Code 27090 Code 27091 Code 27125 Code 27130 Code 27132 Code 27134 Code 27137 Code 27138 Code 27140 Code 27146 Code 27147 Code 27151 Code 27156 Code 27161 Code 27165 Code 27170 Code 27455 Code 29860 Code 29861 Code 29862 Code 29863 Code 29914 Code 29915 Code 29916 Code S2118 Code M05.051 Code M08.959 Code M12.551 Code M12.559 Code M16.0 Code M16.9 Code M80.051A Code M80.059S Code M80.851A Code M80.859S Code M84.451A Code M84.453S Code M84.459A Code M84.459S Code M84.551A Code M84.559S Code M84.651A Code M84.659S Code M84.750A Code M84.759S Code M87.050 Code M87.051 Code M87.059 Code M87.150 Code M87.151 Code M87.159 Code M87.250 Code M87.251 Code M87.256 Code M87.350 Code M87.351 Code M87.353 Code M87.850 Code M87.851 Code M87.859 Code M90.551 Code M90.559 Code M97.01XA Code M97.02XS Code S72.001A Code S72.26XS

Orthopedic Joint Procedures of the Hip for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) Members - (Effective Date - 2027-01-01) 7.01.121

Summary

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What to do

Codes mentioned

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