Why Anthem BCBS Denies Total Hip Replacement
Conservative management not exhausted
BMI exceeds payer threshold (often >40)
Imaging does not show severe joint disease
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
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 Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
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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