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Medicare Advantage Prior Authorization
Joint Replacement Surgery

last updated 2/14/2014 garcarl

23470 Arthroplasty, glenohumeral joint; hemiarthroplasty 
23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) 
24360 Arthroplasty, elbow; with membrane (eg, fascial) 
24361 Arthroplasty, elbow; with distal humeral prosthetic replacement 
24362 Arthroplasty, elbow; with implant and fascia lata ligament reconstruction
24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) 
24365 Arthroplasty, radial head;
24366 Arthroplasty, radial head; with implant 
25332 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation
25441 Arthroplasty with prosthetic replacement; distal radius
25442 Arthroplasty with prosthetic replacement; distal ulna
25443 Arthroplasty with prosthetic replacement; scaphoid carpal (navicular)
25444 Arthroplasty with prosthetic replacement; lunate
25445 Arthroplasty with prosthetic replacement; trapezium 
25446 Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) 
25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints
25449 Revision of arthroplasty, including removal of implant, wrist joint
27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)
27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft 
27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft 
27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft 
27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft 
27138 Revision of total hip arthroplasty; femoral component only, with or without allograft
27412 Autologous chondrocyte implantation, knee
27437 Arthroplasty, patella; without prosthesis 
27438 Arthroplasty, patella; with prosthesis 
27440 Arthroplasty, knee, tibial plateau; 
27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
27442 Arthroplasty, femoral condyles or tibial plateau(s), knee;
27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy 
27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type)
27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment 
27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
27486 Revision of total knee arthroplasty, with or without allograft; 1 component
27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component 
27700 Arthroplasty, ankle
27702 Arthroplasty, ankle; with implant (total ankle) 
27703 Arthroplasty, ankle; revision, total ankle

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