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Knee Arthroplasty - Medicare Advantage (Revised)
Effective date
Nov 2, 2026
Identified
Nov 3, 2026
Previous versions
- Knee Arthroplasty - Medicare Advantage (Revised) · effective Mar 16, 2026
Summary
Humana Medicare Advantage revised its Knee Arthroplasty policy effective 11/02/2026, establishing detailed medical necessity criteria for unicompartmental knee arthroplasty (UKA) procedures. The policy requires prior authorization documentation including specific imaging classifications, failure of conservative treatment, BMI-related weight management education for obese patients, preoperative hemoglobin A1C testing, and absence of listed contraindications before UKA procedures will be covered.
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What to do
Action · 6 steps
01Effective 11/02/2026: For Medicare Advantage members in all applicable jurisdictions, obtain prior authorization before scheduling CPT 27437, 27438, 27440, 27441, 27442, 27443, 27446, or 27599 (UKA procedures).
02Ensure providers submit documentation with claims including: (1) diagnosis of unicompartmental osteoarthritis, osteonecrosis, or post-traumatic joint destruction; (2) moderate-to-severe pain and functional loss documented on standardized scales (KOOS, ICOAP, timed up and go, or 6-minute walk test); (3) preoperative hemoglobin A1C less than 8%; (4) radiographic findings showing Kellgren-Lawrence Grade 4 or Outerbridge Grade 4 disease; (5) evidence of failure of conservative treatment (activity modification, intra-articular injections, NSAIDs, exercise, or weight reduction); (6) for BMI greater than 40, documentation of weight management/weight loss education; and (7) confirmation that none of the listed contraindications are present (angular deformity >5 degrees valgus or >10 degrees varus, ACL deficiency, flexion contracture ≥15 degrees, inflammatory arthritis, or preoperative motion arc limitations per policy).
03Update charge entry to flag UKA codes for prior auth review before claims go out.
04Tell providers and front desk staff that UKA procedures now require prior authorization with detailed preoperative testing and imaging documentation.
05Appeals or resubmissions must include all required medical necessity documentation referenced in the policy.
06Watch for Humana's follow-up guidance on jurisdiction-specific MAC LCDs that may impose additional or alternative requirements.
Codes mentioned
2743727438274402744127442274432744627599
Original notice
Knee Arthroplasty - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.