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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

Effective date
Jan 1, 2027
Identified
Oct 28, 2026

Summary

Excellus BlueCross BlueShield medical policy 7.01.121 covers hip joint procedures for Managed Medicaid (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHP), and Essential Plan (EP) members, with a current effective date of January 1, 2027. The policy sets medical necessity criteria for partial and total hip arthroplasty, revision hip arthroplasty, hip resurfacing, pediatric osteotomy, hip arthroscopy, and hip labral repair, and it lists indications that are not medically necessary. The policy history lists a 09/17/26 new policy and a 10/22/26 off-cycle review that removed site of care criteria and clarified developmental hip dysplasia and primary cause of surgery.

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What to do

Action · 5 steps
01Beginning January 1, 2027: Billing team should make sure the documentation for each hip procedure under this policy supports the criteria the policy lists before claims are sent.
02For total hip arthroplasty, the policy requires a BMI of 40 kg/m2 or less and one of the listed conditions, plus conservative management that includes physical therapy (supervised by a licensed PT, chiropractor, or through tele-rehab PT) for a minimum of 6 weeks during the previous 6 months and pain management.
03The policy lists contraindications for total hip arthroplasty, including diabetes with HbA1c greater than 8%, intra-articular corticosteroid injection within 12 weeks of surgery, and nicotine or tobacco use within six weeks of surgery.
04For hip arthroscopy, the policy lists conditions that are not medically necessary, including bone marrow edema, radiographic or clinical evidence of fracture, and tear involving the abductor, adductor, or hamstring tendon complex, and diagnostic hip arthroscopy is only medically necessary when all of its listed criteria are met.
05Review the criteria for each hip code billed, including the resurfacing, osteotomy, labral repair, and femoroacetabular impingement criteria.

Codes mentioned

27033270502707027071270902709127125271302713227134271372713827140271462714727151271562716127165271702745529860298612986229863299142991529916S2118M87.050M87.150M87.250M87.350M87.850

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.
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Related changes

See all Excellus BlueCross BlueShield changes →
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 policiesNY policy changesOrthopedicsCode 27033Code 27050Code 27070Code 27071Code 27090Code 27091Code 27125Code 27130Code 27132Code 27134Code 27137Code 27138Code 27140Code 27146Code 27147Code 27151Code 27156Code 27161Code 27165Code 27170Code 27455Code 29860Code 29861Code 29862Code 29863Code 29914Code 29915Code 29916Code S2118Code M87.050Code M87.150Code M87.250Code M87.350Code M87.850

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