Coverage Policy Manual
Policy #: 2017017
Category: Surgery
Initiated: January 2018
Last Review: December 2018
  Pilot Policy: Total Arthroplasty-Hip (THA) or Knee (TKA)

Description:
Total hip arthroplasty (THA) is a common surgical procedure for end-stage joint disease or hip joint failure caused by osteoarthritis (OA), rheumatoid arthritis (RA), other types of inflammatory arthritis, avascular necrosis, and injury.
 
Total hip arthroplasty is indicated in patients who have failed conservative or previous surgical treatment options for a deteriorated hip joint and who continue to have persistent, debilitating pain and a significant decrease in the activities of daily living. THA may also be indicated even in the absence of severe pain. Patients with significant deformity and limitation of motion may be candidates if the disability that results is considerable and impairs normal function.
 
Recently, improvements in surgical technique, implants, comprehensive blood management, and multimodal pain management have strikingly reduced the hospital stay and –in some situations—eliminated the need for inpatient hospital admission. Also, advances in physical therapy, anesthesia, earlier ambulation, and improved pain control have contributed to earlier discharge.
 

Policy/
Coverage:
This policy is limited to orthopedic surgeons who are faculty members of the University of Arkansas for Medical Sciences or Arkansas Specialty Hospital and specific to those members meeting criteria in an outpatient facility setting (NOT covered in ASC) for total hip arthroplasty or total knee arthroplasty from January 1, 2019 through December 31, 2019.  This policy may be rescinded at any time by Arkansas Blue Cross Blue Shield, the University of Arkansas for Medical Sciences or Arkansas Specialty Hospital.
 
EFFECTIVE JANUARY 2019
The use of Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) in an outpatient hospital setting (NOT covered in ASC) meets primary coverage criteria provided ALL of the following criteria are met:
 
 
      1. A diagnosis of osteoarthritis (OA), osteonecrosis, rheumatoid arthritis (RA), or other inflammatory arthritis (e.g. psoriatic arthritis), avascular necrosis, or other injury is documented, AND
      2. Radiographic evidence of joint damage, AND
      3. Significant persistent pain and/or  functional limitations that interfere with activities of daily living, (e.g., reduced walking distance, inability to work) AND
      4. Failure and/or contraindication to optimal medical management (including but not limited to medications, physical therapy, weight reduction for obesity), AND
5. Does not have any exclusion as listed below:
 Exclusions:
          •  Age > 70 years old
          • Pregnancy
          • Unable to walk without walker pre-op
          • Chronic opioid use
          • BMI 40 or greater
          • Pre-op Hgb less than 11
          • Limited help at home
          • Sickle Cell DiseaseCardiopulmonary conditions (including but not limited to the following: recent acute MI--< 6 months, unstable angina, history of cardiogenic/non-cardiogenic pulmonary edema, severe valvular heart disease, pulmonary hypertension, severe obstructive l or restrictive lung disease)
          • Recent episode of transient cerebral ischemia or stoke Diabetes with HgbA1c greater than 8.0
          • Previous post-op  ileus
          • Cirrhosis
          • Active untreated bacterial or fungal infection and/or recent sepsis
          • Known history of difficult airway/intubation
          • Neuromuscular disorder impairing respiration or ability to ambulate
          • Difficulty swallowing
          • Stage 4 Kidney Disease (GFR less than 30)
          • History of Urinary retention and BPH
          • Untreated Obstructive Sleep Apnea
          • Current or recent severe upper respiratory infection or pneumonia
          • Known history or strong family history of malignant hyperthermia
          • Anesthesia risk level ASA  3 or greater
          • Poor Health Literacy by preop screening questionnaire
          • Other medical evidence indicating a risk > 25% for need of inpatient admission
          • Surgeon or program director finds any condition which mandates inpatient admission;  AND
 6. Must meet ALL of the following criteria for discharge from the outpatient department:
          •  Walk independently on level ground with walker
          • Climb stairs with assistance if necessary (stairs in home)
          • Bathroom transfers with assistance
          • Able to void independently
          • Tolerating oral  diet with no significant nausea and vomiting
          • Adequate pain control and plans for postoperative pain control
          • Stable vital signs
          • Patient and Coach comfortable with Discharge
          • At discharge, patients will have telephone availability of a joint replacement team member 24 hours a day, seven days a week.
 
UAMS team and Arkansas Specialty Hospital will be responsible for:
 
Standard quality assessments with tracking and reporting of readmission rates, infection rates, dislocation rates, etc. AND will include patient Satisfaction and HOOS, Jr for hips and KOOS for knees.
 
ABCBS will be responsible for:
 
Standard claims reporting (including episode costs)
 
 

Rationale:
This policy is limited to orthopedic surgeons who are faculty members of the University of Arkansas for Medical Sciences or Arkansas Specialty Hospital and specific to those members meeting criteria in an outpatient facility setting (NOT covered in ASC) for total hip arthroplasty or total knee arthroplasty from January 1, 2019 through December 31, 2019.  This policy may be rescinded at any time by Arkansas Blue Cross Blue Shield, the University of Arkansas for Medical Sciences or Arkansas Specialty Hospital.

CPT/HCPCS:
27130Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
27446Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
27447Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.