Why MA Plans Denies Total Hip Replacement
Conservative management not exhausted
BMI exceeds payer threshold (often >40)
Imaging does not show severe joint disease
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
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 MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
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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