S-39-008

HIGHMARK MEDICARE ADVANTAGE MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

S-39-008

Topic:

Lower Extremity Major Joint Replacement (Hip and Knee)

Section:

Surgery

Effective Date:

November 14, 2019

Issued Date:

September 28, 2020

Last Revision Date:

August 2020

Lower extremity major joint replacement or arthroplasty refers to the replacement of the hip or knee joint. The goal of total hip or knee replacement surgery is to relieve pain and improve or increase functional activity.

Policy Position

To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page.

27130	27132	27134	27137	27138	27445	27447
27486	27487

Covered Diagnosis Codes for Procedure Codes 27130, 27132, 27134, 27137, and 27138

C40.20	C40.21	C40.22	C49.20	C49.21	C49.22	D16.21
D16.22	D21.21	D21.22	L40.50	L40.54	L40.59	M05.051
M05.052	M05.451	M05.452	M05.751	M05.752	M05.851	M05.852
M06.051	M06.052	M07.651	M07.652	M08.051	M08.052	M08.251
M08.252	M08.3	M08.451	M08.452	M08.851	M08.852	M08.951
M08.952	M12.051	M12.052	M12.351	M12.352	M12.551	M12.552
M12.851	M12.852	M12.9	M13.0	M13.151	M13.152	M16.0
M16.11	M16.12	M16.2	M16.31	M16.32	M16.4	M16.51
M16.52	M16.9	M24.651	M24.652	M24.851	M24.852	M24.9
M25.251	M25.252	M25.351	M25.352	M25.551	M25.552	M25.559
M80.051A	M80.051D	M80.051G	M80.051K	M80.051P	M80.051S	M80.052A
M80.052D	M80.052G	M80.052K	M80.052P	M80.052S	M80.061A	M80.061D
M80.061G	M80.061K	M80.061P	M80.061S	M80.062A	M80.062D	M80.062G
M80.062K	M80.062P	M80.062S	M80.851A	M80.851D	M80.851G	M80.851K
M80.851P	M80.851S	M80.852A	M80.852D	M80.852G	M80.852K	M80.852P
M80.852S	M80.861A	M80.861D	M80.861G	M80.861K	M80.861P	M80.861S
M80.862A	M80.862D	M80.862G	M80.862K	M80.862P	M80.862S	M84.351A
M84.351D	M84.351G	M84.351K	M84.351P	M84.351S	M84.352A	M84.352D
M84.352G	M84.352K	M84.352P	M84.352S	M84.359A	M84.359D	M84.359G
M84.359K	M84.359P	M84.359S	M84.451A	M84.451D	M84.451G	M84.451K
M84.451P	M84.451S	M84.452A	M84.452D	M84.452G	M84.452K	M84.452P
M84.452S	M84.459A	M84.459D	M84.459G	M84.459K	M84.459P	M84.459S
M84.551A	M84.551D	M84.551G	M84.551K	M84.551P	M84.551S	M84.552A
M84.552D	M84.552G	M84.552K	M84.552P	M84.552S	M84.559A	M84.559D
M84.559G	M84.559K	M84.559P	M84.559S	M87.051	M87.052	M87.10
M87.151	M87.152	M87.20	M87.251	M87.252	M87.351	M87.352
M88.861	M88.862	M96.0	M97.01XA	M97.01XD	M97.01XS	M97.02XA
M97.02XD	M97.02XS	M97.9XXA	M97.9XXD	M97.9XXS	Q65.00	Q65.01
Q65.02	Q65.1	S32.401A	S32.401B	S32.401D	S32.401G	S32.401K
S32.401S	S32.402A	S32.402B	S32.402D	S32.402G	S32.402K	S32.402S
S32.411A	S32.411B	S32.411D	S32.411G	S32.411K	S32.411S	S32.412A
S32.412B	S32.412D	S32.412G	S32.412K	S32.412S	S32.414A	S32.414B
S32.414D	S32.414G	S32.414K	S32.414S	S32.415A	S32.415B	S32.415D
S32.415G	S32.415K	S32.415S	S32.421A	S32.421B	S32.421D	S32.421G
S32.421K	S32.421S	S32.422A	S32.422B	S32.422D	S32.422G	S32.422K
S32.422S	S32.424A	S32.424B	S32.424D	S32.424G	S32.424K	S32.424S
S32.425A	S32.425B	S32.425D	S32.425G	S32.425K	S32.425S	S32.431A
S32.431B	S32.431D	S32.431G	S32.431K	S32.431S	S32.432A	S32.432B
S32.432D	S32.432G	S32.432K	S32.432S	S32.434A	S32.434B	S32.434D
S32.434G	S32.434K	S32.434S	S32.435A	S32.435B	S32.435D	S32.435G
S32.435K	S32.435S	S32.441A	S32.441B	S32.441D	S32.441G	S32.441K
S32.441S	S32.442A	S32.442B	S32.442D	S32.442G	S32.442K	S32.442S
S32.444A	S32.444B	S32.444D	S32.444G	S32.444K	S32.444S	S32.445A
S32.445B	S32.445D	S32.445G	S32.445K	S32.445S	S32.451A	S32.451B
S32.451D	S32.451G	S32.451K	S32.451S	S32.452A	S32.452B	S32.452D
S32.452G	S32.452K	S32.452S	S32.454A	S32.454B	S32.454D	S32.454G
S32.454K	S32.454S	S32.455A	S32.455B	S32.455D	S32.455G	S32.455K
S32.455S	S32.461A	S32.461B	S32.461D	S32.461G	S32.461K	S32.461S
S32.462A	S32.462B	S32.462D	S32.462G	S32.462K	S32.462S	S32.464A
S32.464B	S32.464D	S32.464G	S32.464K	S32.464S	S32.465A	S32.465B
S32.465D	S32.465G	S32.465K	S32.465S	S32.471A	S32.471B	S32.471D
S32.471G	S32.471K	S32.471S	S32.472A	S32.472B	S32.472D	S32.472G
S32.472K	S32.472S	S32.474A	S32.474B	S32.474D	S32.474G	S32.474K
S32.474S	S32.475A	S32.475B	S32.475D	S32.475G	S32.475K	S32.475S
S32.481A	S32.481B	S32.481D	S32.481G	S32.481K	S32.481S	S32.482A
S32.482B	S32.482D	S32.482G	S32.482K	S32.482S	S32.484A	S32.484B
S32.484D	S32.484G	S32.484K	S32.484S	S32.485A	S32.485B	S32.485D
S32.485G	S32.485K	S32.485S	S32.491A	S32.491B	S32.491D	S32.491G
S32.491K	S32.491S	S32.492A	S32.492B	S32.492D	S32.492G	S32.492K
S32.492S	S72.001A	S72.001C	S72.001D	S72.001E	S72.001F	S72.001G
S72.001H	S72.001J	S72.001K	S72.001M	S72.001N	S72.001P	S72.001Q
S72.001R	S72.001S	S72.002A	S72.002C	S72.002D	S72.002E	S72.002F
S72.002G	S72.002H	S72.002J	S72.002K	S72.002M	S72.002N	S72.002P
S72.002Q	S72.002R	S72.002S	S72.011A	S72.011C	S72.011D	S72.011E
S72.011F	S72.011G	S72.011H	S72.011J	S72.011K	S72.011M	S72.011N
S72.011P	S72.011Q	S72.011R	S72.011S	S72.012A	S72.012C	S72.012D
S72.012E	S72.012F	S72.012G	S72.012H	S72.012J	S72.012K	S72.012M
S72.012N	S72.012P	S72.012Q	S72.012R	S72.012S	S72.021A	S72.021C
S72.021D	S72.021E	S72.021F	S72.021G	S72.021H	S72.021J	S72.021K
S72.021M	S72.021N	S72.021P	S72.021Q	S72.021R	S72.021S	S72.022A
S72.022C	S72.022D	S72.022E	S72.022F	S72.022G	S72.022H	S72.022J
S72.022K	S72.022M	S72.022N	S72.022P	S72.022Q	S72.022R	S72.022S
S72.024A	S72.024C	S72.024D	S72.024E	S72.024F	S72.024G	S72.024H
S72.024J	S72.024K	S72.024M	S72.024N	S72.024P	S72.024Q	S72.024R
S72.024S	S72.025A	S72.025C	S72.025D	S72.025E	S72.025F	S72.025G
S72.025H	S72.025J	S72.025K	S72.025M	S72.025N	S72.025P	S72.025Q
S72.025R	S72.025S	S72.031A	S72.031C	S72.031D	S72.031E	S72.031F
S72.031G	S72.031H	S72.031J	S72.031K	S72.031M	S72.031N	S72.031P
S72.031Q	S72.031R	S72.031S	S72.032A	S72.032C	S72.032D	S72.032E
S72.032F	S72.032G	S72.032H	S72.032J	S72.032K	S72.032M	S72.032N
S72.032P	S72.032Q	S72.032R	S72.032S	S72.034A	S72.034C	S72.034D
S72.034E	S72.034F	S72.034G	S72.034H	S72.034J	S72.034K	S72.034M
S72.034N	S72.034P	S72.034Q	S72.034R	S72.034S	S72.035A	S72.035C
S72.035D	S72.035E	S72.035F	S72.035G	S72.035H	S72.035J	S72.035K
S72.035M	S72.035N	S72.035P	S72.035Q	S72.035R	S72.035S	S72.041A
S72.041C	S72.041D	S72.041E	S72.041F	S72.041G	S72.041H	S72.041J
S72.041K	S72.041M	S72.041N	S72.041P	S72.041Q	S72.041R	S72.041S
S72.042A	S72.042C	S72.042D	S72.042E	S72.042F	S72.042G	S72.042H
S72.042J	S72.042K	S72.042M	S72.042N	S72.042P	S72.042Q	S72.042R
S72.042S	S72.044A	S72.044C	S72.044D	S72.044E	S72.044F	S72.044G
S72.044H	S72.044J	S72.044K	S72.044M	S72.044N	S72.044P	S72.044Q
S72.044R	S72.044S	S72.045A	S72.045C	S72.045D	S72.045E	S72.045F
S72.045G	S72.045H	S72.045J	S72.045K	S72.045M	S72.045N	S72.045P
S72.045Q	S72.045R	S72.045S	S72.051A	S72.051C	S72.051D	S72.051E
S72.051F	S72.051G	S72.051H	S72.051J	S72.051K	S72.051M	S72.051N
S72.051P	S72.051Q	S72.051R	S72.051S	S72.052A	S72.052C	S72.052D
S72.052E	S72.052F	S72.052G	S72.052H	S72.052J	S72.052K	S72.052M
S72.052N	S72.052P	S72.052Q	S72.052R	S72.052S	S72.061A	S72.061C
S72.061D	S72.061E	S72.061F	S72.061G	S72.061H	S72.061J	S72.061K
S72.061M	S72.061N	S72.061P	S72.061Q	S72.061R	S72.061S	S72.062A
S72.062C	S72.062D	S72.062E	S72.062F	S72.062G	S72.062H	S72.062J
S72.062K	S72.062M	S72.062N	S72.062P	S72.062Q	S72.062R	S72.062S
S72.064A	S72.064C	S72.064D	S72.064E	S72.064F	S72.064G	S72.064H
S72.064J	S72.064K	S72.064M	S72.064N	S72.064P	S72.064Q	S72.064R
S72.064S	S72.065A	S72.065C	S72.065D	S72.065E	S72.065F	S72.065G
S72.065H	S72.065J	S72.065K	S72.065M	S72.065N	S72.065P	S72.065Q
S72.065R	S72.065S	S72.091A	S72.091B	S72.091C	S72.091D	S72.091E
S72.091F	S72.091G	S72.091H	S72.091J	S72.091K	S72.091M	S72.091N
S72.091P	S72.091Q	S72.091R	S72.091S	S72.092A	S72.092B	S72.092C
S72.092D	S72.092E	S72.092F	S72.092G	S72.092H	S72.092J	S72.092K
S72.092M	S72.092N	S72.092P	S72.092Q	S72.092R	S72.092S	S72.101A
S72.101B	S72.101C	S72.101D	S72.101E	S72.101F	S72.101G	S72.101H
S72.101J	S72.101K	S72.101M	S72.101N	S72.101P	S72.101Q	S72.101R
S72.101S	S72.102A	S72.102B	S72.102C	S72.102D	S72.102E	S72.102F
S72.102G	S72.102H	S72.102J	S72.102K	S72.102M	S72.102N	S72.102P
S72.102Q	S72.102R	S72.102S	S72.111A	S72.111B	S72.111C	S72.111D
S72.111E	S72.111F	S72.111G	S72.111H	S72.111J	S72.111K	S72.111M
S72.111N	S72.111P	S72.111Q	S72.111R	S72.111S	S72.112A	S72.112B
S72.112C	S72.112D	S72.112E	S72.112F	S72.112G	S72.112H	S72.112J
S72.112K	S72.112M	S72.112N	S72.112P	S72.112Q	S72.112R	S72.112S
S72.114A	S72.114B	S72.114C	S72.114D	S72.114E	S72.114F	S72.114G
S72.114H	S72.114J	S72.114K	S72.114M	S72.114N	S72.114P	S72.114Q
S72.114R	S72.114S	S72.115A	S72.115B	S72.115C	S72.115D	S72.115E
S72.115F	S72.115G	S72.115H	S72.115J	S72.115K	S72.115M	S72.115N
S72.115P	S72.115Q	S72.115R	S72.115S	S72.121A	S72.121B	S72.121C
S72.121D	S72.121E	S72.121F	S72.121G	S72.121H	S72.121J	S72.121K
S72.121M	S72.121N	S72.121P	S72.121Q	S72.121R	S72.121S	S72.122A
S72.122B	S72.122C	S72.122D	S72.122E	S72.122F	S72.122G	S72.122H
S72.122J	S72.122K	S72.122M	S72.122N	S72.122P	S72.122Q	S72.122R
S72.122S	S72.124A	S72.124B	S72.124C	S72.124D	S72.124E	S72.124F
S72.124G	S72.124H	S72.124J	S72.124K	S72.124M	S72.124N	S72.124P
S72.124Q	S72.124R	S72.124S	S72.125A	S72.125B	S72.125C	S72.125D
S72.125E	S72.125F	S72.125G	S72.125H	S72.125J	S72.125K	S72.125M
S72.125N	S72.125P	S72.125Q	S72.125R	S72.125S	S72.131A	S72.131B
S72.131C	S72.131D	S72.131E	S72.131F	S72.131G	S72.131H	S72.131J
S72.131K	S72.131M	S72.131N	S72.131P	S72.131Q	S72.131R	S72.131S
S72.132A	S72.132B	S72.132C	S72.132D	S72.132E	S72.132F	S72.132G
S72.132H	S72.132J	S72.132K	S72.132M	S72.132N	S72.132P	S72.132Q
S72.132R	S72.132S	S72.134A	S72.134B	S72.134C	S72.134D	S72.134E
S72.134F	S72.134G	S72.134H	S72.134J	S72.134K	S72.134M	S72.134N
S72.134P	S72.134Q	S72.134R	S72.134S	S72.135A	S72.135B	S72.135C
S72.135D	S72.135E	S72.135F	S72.135G	S72.135H	S72.135J	S72.135K
S72.135M	S72.135N	S72.135P	S72.135Q	S72.135R	S72.135S	S72.141A
S72.141B	S72.141C	S72.141D	S72.141E	S72.141F	S72.141G	S72.141H
S72.141J	S72.141K	S72.141M	S72.141N	S72.141P	S72.141Q	S72.141R
S72.141S	S72.142A	S72.142B	S72.142C	S72.142D	S72.142E	S72.142F
S72.142G	S72.142H	S72.142J	S72.142K	S72.142M	S72.142N	S72.142P
S72.142Q	S72.142R	S72.142S	S72.144A	S72.144B	S72.144C	S72.144D
S72.144E	S72.144F	S72.144G	S72.144H	S72.144J	S72.144K	S72.144M
S72.144N	S72.144P	S72.144Q	S72.144R	S72.144S	S72.145A	S72.145B
S72.145C	S72.145D	S72.145E	S72.145F	S72.145G	S72.145H	S72.145J
S72.145K	S72.145M	S72.145N	S72.145P	S72.145Q	S72.145R	S72.145S
S72.21XA	S72.21XB	S72.21XC	S72.21XD	S72.21XE	S72.21XF	S72.21XG
S72.21XH	S72.21XJ	S72.21XK	S72.21XM	S72.21XN	S72.21XP	S72.21XQ
S72.21XR	S72.21XS	S72.22XA	S72.22XB	S72.22XC	S72.22XD	S72.22XE
S72.22XF	S72.22XG	S72.22XH	S72.22XJ	S72.22XK	S72.22XM	S72.22XN
S72.22XP	S72.22XQ	S72.22XR	S72.22XS	S72.24XA	S72.24XB	S72.24XC
S72.24XD	S72.24XE	S72.24XF	S72.24XG	S72.24XH	S72.24XJ	S72.24XK
S72.24XM	S72.24XN	S72.24XP	S72.24XQ	S72.24XR	S72.24XS	S72.25XA
S72.25XB	S72.25XC	S72.25XD	S72.25XE	S72.25XF	S72.25XG	S72.25XH
S72.25XJ	S72.25XK	S72.25XM	S72.25XN	S72.25XP	S72.25XQ	S72.25XR
S72.25XS	S79.001A	S79.001D	S79.001G	S79.001K	S79.001P	S79.001S
S79.002A	S79.002D	S79.002G	S79.002K	S79.002P	S79.002S	S79.011A
S79.011D	S79.011G	S79.011K	S79.011P	S79.011S	S79.012A	S79.012D
S79.012G	S79.012K	S79.012P	S79.012S	T84.010A	T84.010D	T84.010S
T84.011A	T84.011D	T84.011S	T84.020A	T84.020D	T84.020S	T84.021A
T84.021D	T84.021S	T84.030A	T84.030D	T84.030S	T84.031A	T84.031D
T84.031S	T84.050A	T84.050D	T84.050S	T84.051A	T84.051D	T84.051S
T84.060A	T84.060D	T84.060S	T84.061A	T84.061D	T84.061S	T84.090A
T84.090D	T84.090S	T84.091A	T84.091D	T84.091S	T84.498A	T84.498D
T84.498S	T84.51XA	T84.51XD	T84.51XS	T84.52XA	T84.52XD	T84.52XS
Z47.32	Z89.621*	Z89.622*	Z96.641*	Z96.642*	Z96.643*	Z96.649*

*Note: Diagnosis codes Z89.621, Z89.622, Z96.641, Z96.642, Z96.643, and Z96.649 are considered status codes and should not be used with a diagnosis code from one (1) of the body system chapters, if the diagnosis code includes the information provided by the status code.

Covered Diagnosis Codes for Procedure Codes 27445, 27447, 27486, and 27487

C40.20	C40.21	C40.22	D16.20	D16.21	D16.22	L40.50
L40.54	M05.00	M05.061	M05.062	M05.069	M05.09	M05.40
M05.461	M05.462	M05.469	M05.50	M05.561	M05.562	M05.569
M05.70	M05.761	M05.762	M05.769	M05.80	M05.861	M05.862
M05.869	M05.9	M06.00	M06.061	M06.062	M06.069	M06.9
M08.261	M08.262	M08.461	M08.462	M08.861	M08.862	M08.961
M08.962	M12.00	M12.061	M12.062	M12.069	M12.561	M12.562
M12.569	M17.0	M17.10	M17.11	M17.12	M17.2	M17.30
M17.31	M17.32	M17.9	M23.50	M23.51	M23.52	M24.661
M24.662	M24.669	M25.261	M25.262	M25.269	M25.561	M25.562
M25.569	M25.9	M87.051	M87.052	M87.059	M96.0	M97.11XA
M97.11XD	M97.11XS	M97.12XA	M97.12XD	M97.12XS	M97.9XXA	M97.9XXD
M97.9XXS	T84.012A	T84.012D	T84.012S	T84.013A	T84.013D	T84.013S
T84.019A	T84.019D	T84.019S	T84.022A	T84.022D	T84.022S	T84.023A
T84.023D	T84.023S	T84.029A	T84.029D	T84.029S	T84.032A	T84.032D
T84.032S	T84.033A	T84.033D	T84.033S	T84.039A	T84.039D	T84.039S
T84.052A	T84.052D	T84.052S	T84.053A	T84.053D	T84.053S	T84.059A
T84.059D	T84.059S	T84.062A	T84.062D	T84.062S	T84.063A	T84.063D
T84.063S	T84.069A	T84.069D	T84.069S	T84.092A	T84.092D	T84.092S
T84.093A	T84.093D	T84.093S	T84.099A	T84.099D	T84.099S	T84.428A
T84.428D	T84.428S	T84.498A	T84.498D	T84.498S	T84.50XA	T84.50XD
T84.50XS	T84.53XA	T84.53XD	T84.53XS	T84.54XA	T84.54XD	T84.54XS
Z47.33	Z89.521*	Z89.522*	Z96.651*	Z96.652*	Z96.653*	Z96.659*

*Note: Diagnosis codes Z89.521, Z89.522, Z96.651, Z96.652, Z96.653, and Z96.659 are considered status codes and should not be used with a diagnosis code from one (1) of the body system chapters, if the diagnosis code includes the information provided by the status code.

Related Policies

Refer to Medicare Advantage medical policy N-28 Assistant at Surgery Services for additional information.

The policy position applies to all Medicare Advantage lines of business

Links

CMS Links

CMS Website

Article Links

Article Link

LCD Links

LCD Link

References

Novitas Solutions, Inc. LCD L36007. Revised 11/14/2019 (R10).
Novitas Solutions, Inc. LCA A56796. Revised 11/14/2019 (R1).

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.