Why Aetna Denies Total Hip Replacement
Conservative management not exhausted
BMI exceeds payer threshold (often >40)
Imaging does not show severe joint disease
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Building Your Medical Necessity Argument
Document Kellgren-Lawrence grade on imaging
Show failure of NSAIDs, PT, injections, activity modification
Note functional limitations using validated outcome measures
Address BMI and optimization if applicable
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- AAOS Clinical Practice Guidelines for Hip OA
- MCG Criteria for Total Joint Replacement
Relevant CPT Codes
Specialty: Orthopedics
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