L32078-LCD

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Automated World Health

Local Coverage Determination (LCD) for Major Joint Replacement (Hip and Knee) (L32078)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L32078

LCD Title Major Joint Replacement (Hip and Knee)

Contractor's Determination Number A27130

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 10/16/2011

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/16/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Online Manual System, Pub 100-03, Medicare National Coverage Determinations, Chapter 1, Part 1, Section

150.9

CMS Online Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.2

Indications and Limitations of Coverage and/or Medical Necessity

Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The knee is the largest joint in the body and includes the lower end of the femur, the upper end of the tibia and the patella. The knee joint has three compartments, the medial, the lateral and the patellofemoral. The surfaces of these compartments are covered with articular cartilage and are bathed in synovial fluid. The bones of the knee joint work together, allowing the knee to function smoothly. The hip is a large weight bearing joint made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and are bathed in synovial fluid produced by a synovial membrane.

The most common reason for total knee replacement surgery is arthritis of the knee joint. Types of arthritis include osteoarthritis, rheumatoid arthritis and traumatic arthritis (arthritis which occurs as a result of injury). This arthritis causes a severe limitation in the activities of daily living, including difficulty with walking, squatting, and climbing stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for a long time. Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as steroid injections and physical therapy. Osteonecrosis and malignancy are additional reasons to proceed with total knee replacement surgery. The goal of total knee replacement surgery is to relieve pain and improve or increase patient function.

Total hip replacement surgery is most often performed due to severe pain caused by osteoarthritis of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also causes for hip replacement surgery. The pain from the damaged joint usually limits activities of daily living, such as walking, bathing and cooking. The pain can also cause disruption of sleep due to the inability to lie on the hip while in bed. Pain relief not achieved by taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as physical therapy, activity modification and (in some patients) assistive device use are reasons for proceeding with a total hip replacement. The goal of total hip replacement surgery is to relieve pain and improve or increase patient function.

Occasionally, there may be a need to redo a total hip or total knee replacement. This is often referred to as a revision total knee or revision total hip. Circumstances that lead to the need for a revision total hip or knee are continued disabling pain, continued decline in function which can be attributed to failure of the primary joint replacement. Failure can be due to infection involving the joint, substantial bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components and wear of the prosthetic components.

Indications

Medicare Administrative Contractor (MAC) Jurisdiction 9 (J9) will consider total knee replacement surgery medically necessary when oneormore of the following criteria are met:

*See Documentation Requirements section for additional information

Total knee arthroplasty (TKA)

• Failure of a previous osteotomy; or

• Distal femur fracture; or

• Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or

• Failure of previous unicompartmental knee replacement; or

• Avascular necrosis of the knee; or

• Proximal tibia fracture; or

• Advanced joint disease demonstrated by :

• Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); and

• Pain or functional disability from injury due to trauma or arthritis of the joint; and

• Unsuccessful history of appropriate conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. Non surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following: anti- inflammatory medications, analgesics, flexibility and muscle strengthening exercises, supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], activity restrictions as is reasonable, assistive device use, weight reduction as appropriate, therapeutic injections into the knee as appropriate.

Replacement/Revision total knee arthroplasty

• Disabling pain or functional disability; or

• Progressive and substantial bone loss; or

• Fracture or dislocation of the patella; or

• Infection; or

• Periprosthetic fracture or aseptic loosening; or

• Failure and wear of the prosthetic components; or

• Dislocation of the knee joint; or

• Instability of the knee joint

MAC J9 will consider total hip replacement surgery medically necessary when one or more of the following criteria are met:

*See Documentation Requirements for additional information

Total hip arthroplasty (THA)

• Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or

• Avascular necrosis (osteonecrosis of femoral head); or

• Fracture of the femoral neck; or

• Acetabular fracture; or

• Non-union or failure of previous hip fracture surgery; or

• Mal-union of acetabular or proximal femur fracture; or

• Advanced joint disease demonstrated by:

• Pain or functional disability from injury due to trauma or arthritis of the joint); and

Replacement/Revision total hip arthroplasty

• Instability of one or both components; or

• Fracture or mechanical failure of the implant; or

• Recurrent or irreducible dislocation; or

• Infection; or

• Treatment of a displaced periprosthetic fracture; or

• Clinically significant leg length inequality; or

• Progressive or substantial bone loss; or

• Clinically significant audible noise; or

• Adverse local tissue reaction

Limitations

MAC J9 will not consider a total knee replacement or total hip replacement medically necessary when the following contraindications are present:

• Active infection of the hip or knee joint or active systemic bacteremia

• Active skin infection or open wound within the planned surgical site of the hip or knee

• Neuropathic arthritis

• Rapidly progressive neurological disease

This local coverage determination (LCD) is only addressing medical necessity criteria for performing total hip and knee replacement surgery. With respect to knee replacement surgery, there is a form of knee joint replacement surgery called unicompartmental knee replacement. This is typically done for patients with osteoarthritis of the knee in which the damage is contained to one compartment of the knee. The indications outlined in this LCD are not to be applied for unicompartmental knee replacement surgery. Failed previous unicompartmental joint replacement is an indication for performing a total knee arthroplasty.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A)

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0360 Operating Room Services - General Classification

CPT/HCPCS Codes

Part B of A services

Total Hip 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

Part B of A services

Total Knee Arthroplasty

27445 ARTHROPLASTY, KNEE, HINGE PROSTHESIS (EG, WALLDIUS TYPE)

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

ICD-9 Codes that Support Medical Necessity

For inpatient hospital only the following ICD-9 CM PROCEDURE CODE should be used

Total Hip Arthroplasty

00.70 Revision of hip replacement, both acetabular and femoral components

81.51 Total hip replacement

81.53 Revision of hip replacement, not otherwise specified

Total Knee Replacement

00.80 Revision of knee replacement, total (all components)

81.54 Total knee replacement

81.55 Revision of knee replacement, not otherwise specified

XX000 Not Applicable

ICD-9CM diagnosis codes for Total Hip Arthroplasty

170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB

171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

213.7 BENIGN NEOPLASM OF LONG BONES OF LOWER LIMB

215.3 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

714.0 RHEUMATOID ARTHRITIS

714.30 - 714.33 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS - MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS

715.15 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING PELVIC REGION AND THIGH

715.25 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING PELVIC REGION AND THIGH

715.35 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING PELVIC REGION AND THIGH

715.95 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING PELVIC REGION AND THIGH

716.15 TRAUMATIC ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

716.55 UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING PELVIC REGION AND THIGH

716.65 UNSPECIFIED MONOARTHRITIS INVOLVING PELVIC REGION AND THIGH

716.85 OTHER SPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

716.95 UNSPECIFIED ARTHROPATHY INVOLVING PELVIC REGION AND THIGH

718.55 ANKYLOSIS OF JOINT OF PELVIC REGION AND THIGH

718.65 UNSPECIFIED INTRAPELVIC PROTRUSION OF ACETABULUM PELVIC REGION AND THIGH

718.85 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING PELVIC REGION AND THIGH

718.95 UNSPECIFIED DERANGEMENT OF JOINT OF PELVIC REGION AND THIGH

719.35 PALINDROMIC RHEUMATISM INVOLVING PELVIC REGION AND THIGH

719.45 PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH

731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR

733.14 PATHOLOGICAL FRACTURE OF NECK OF FEMUR

733.40 ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED

733.42 ASEPTIC NECROSIS OF HEAD AND NECK OF FEMUR

733.82 NONUNION OF FRACTURE

733.96 STRESS FRACTURE OF FEMORAL NECK

754.30 CONGENITAL DISLOCATION OF HIP UNILATERAL

755.63 OTHER CONGENITAL DEFORMITY OF HIP (JOINT)

808.1 CLOSED FRACTURE OF ACETABULUM

808.2 OPEN FRACTURE OF ACETABULUM

820.00-820.9 FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN

996.40 - 996.49* UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT - OTHER MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT

996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS V43.64* HIP JOINT REPLACEMENT

*Note: ICD-9- CM code V43.64 should not be used as a primary diagnosis code when billing for a total hip replacement. It should be used in conjunction with a diagnosis code found in group 996.40-996.49.

ICD-9 CM diagnosis codes for Total Knee Arthroplasty

170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB

171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

213.7 BENIGN NEOPLASM OF LONG BONES OF LOWER LIMB

215.3 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

714.0 RHEUMATOID ARTHRITIS

715.16 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING LOWER LEG

715.26 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING LOWER LEG

715.36 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING LOWER LEG

715.96 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING LOWER LEG

716.16 TRAUMATIC ARTHROPATHY INVOLVING LOWER LEG

718.56 ANKYLOSIS OF LOWER LEG JOINT

718.86 OTHER JOINT DERANGEMENT NOT ELSEWHERE CLASSIFIED INVOLVING LOWER LEG

719.46 PAIN IN JOINT INVOLVING LOWER LEG

719.96 UNSPECIFIED DISORDER OF LOWER LEG JOINT

733.43 ASEPTIC NECROSIS OF MEDIAL FEMORAL CONDYLE

996.40 - 996.49* UNSPECIFIED MECHANICAL COMPLICATION OF INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT - OTHER MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPEDIC DEVICE, IMPLANT, AND GRAFT

996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS V43.65* KNEE JOINT REPLACEMENT

*Note: ICD-9- CM code V43.65 should not be used as a primary diagnosis code when billing for a total hip replacement. It should be used in conjunction with a diagnosis code found in group 996.40-996.49.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements

The medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed. The documentation must be made available to MAC J9 upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.

A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD. Other relevant information addressing coverage criteria related to the patients episode of care prior to the hospitalization, should be included in the hospital record.

When the procedure is indicated for advanced joint disease, the following should be documented in the medical record:

1. ) Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI should demonstrate one of the following: a) subchondral cysts, b) subchondral sclerosis, c) periarticular osteophytes, d) joint subluxation,

e) joint space narrowing, or f) avascular necrosis.

2. ) Pain or functional disability at the hip or knee. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.

3. ) Unsuccessful conservative therapy (non-surgical medical management). The documentation should demonstrate a history of a reasonable attempt (usually 3 months or more) at conservative therapy as appropriate for the patient in their current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management.

4. ) For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.

Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:

1. ) Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture).

2. ) Pain at the hip or knee when indicated as a reason for the procedure (e.g., for revision/replacement TKA/THA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing.

3. ) For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record

4. ) When infection is the reason for revision TKA or THA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.

In the instance that the patient is undergoing a bilateral knee or hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing THA or TKA bilaterally.

Any major procedure has significant benefit and risk (injury or death) that the treating physician discusses with the patient. To meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the physician’s documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) can be denied. If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patient’s episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre procedure documentation. For

example, if certain conservative measures are not necessary for a given patient, it should be directly noted in the pre procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.

When reviewing claims for procedures with DRGs, the CMS online Manual, Pub 100-08, Chapter 6, Section, 6.5.2 states the following:

Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters they may be subject to review for medical necessity.

The devices/implants utilized for total knee and total hip replacement surgeries are regulated by the FDA as medical devices. The devices used should be class II or class III devices that meet the requirements outlined in CFR 21, Chapter 1, subchapter H, Part 888

(http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFR Part=888)

The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that “reasonable and necessary" services

are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and

necessary only if performed by appropriately trained providers. This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.

Sources of Information and Basis for Decision

Ackerman, I., Bennell, K., and Osborne, R. (2011). Decline in health-realted quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study. BMC Musculoskeletal Disorders 12:108

Aetna Clinical Policy Bulletin: Total hip implants, number 0287.

Agency for Healthcare Research and Quality (AHRQ). Evidence Report/Technology Assessment: Number 86. Total Knee Replacement. Retrieved from https://www.ahrq.gov/clinical/epcsums/kneesum.htm

American Academy of Orthopaedic Surgeons (2008). Treatment of osteoarthritis of the knee (non-arthroplasty): Full guideline.

Care Allies medical necessity guidelines: Knee arthroplasty, number 0347. Cigna medical coverage policy: Knee arthroplasty/replacement, number 0347.

Cigna medical coverage policy: Total hip replacement with metal-on-metal and ceramic-on-ceramic prosthesis, number 0214.

Code of Federal Regulations, Title 21, Chapter 1, Subchapter H, Part 888. Retrieved from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=888

Dennis, d., Berry, D., Engh, G. et al (2008). AAOS Symposium: Revision total knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons; 16:442-454.

Emedicine. Total knee arthroplasty. Retrieved from https://emedicne.medscape.com/article/1250275-overview Feeley, B., Gallo, R., Sherman, S., Williams, R. (2010). Review Article: Management of osteoarthritis of the knee

in the active patient. Journal of the American Academy of Orthopaedic Surgeons; 18: 406-416.

InterQual® 2011 Procedures Adult Criteria, Total Joint Replacement, Knee and Hip & Removal and Replacement , Total Joint Replacement Knee and Hip. McKesson Corporation.

Milliman Care Guidelines® 2011. Inpatient and Surgical Care 15th Edition. Knee Arthroplasty and Hip Arthroplasty. Milliman Care Guidelines LLC.

National Guideline Clearinghouse. Osteoarthritis. The care and management of osteoarthritis in adults. Retrieved from https://www.guideline.gov

O’Connor, M. (2011). Implant Survival, knee function and pain relief after TKA. Are there differences between men and women? Clinical Orthopaedics and Related Research 469:1846-1851.

U.S. National Library of Medicine, National Institute of Health. Hip joint replacement. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/002975.htm

Your Orthopaedic Connection (2007). Hip implants. Retrieved from https://www.orthoinfo.aaos.org. Please note that this reference is not endorsed as official guidelines from the AAOS.

Your Orthopaedic Connection (2007). Joint revision surgery-when do I need it? Retrieved from https://www.orthoinfo.aaos.org. Please note that this reference is not endorsed as official guidelines from the AAOS.

Your Orthopaedic Connection (2007). Osteoarthritis of the hip. Retrieved from https://www.orthoinfo.aaos.org . Please note that this reference is not endorsed as official guidelines from the AAOS.

Your Orthopaedic Connection (2003). Surgical treatment of osteoarthritis of the knee. Retrieved from https://orthoinfo.aaos.org . Please note that this reference is not endorsed as official guidelines from the AAOS.

Your Orthopaedic Connection (2009). Total hip replacement. Retrieved from https://orthoinfo.aaos.org . Please note that this reference is not endorsed as official guidelines from the AAOS.

Your Orthopaedic Connection (2009). Total knee replacement. Retrieved from https://orthoinfo.aaos.org. Please note that this reference is not endorsed as official guidelines from the AAOS.

Your Orthopaedic Connection (2010). Unicompartmental knee replacement. Retrieved from https://orthoinfo.aasos.org. Please note that this reference is not endorsed as official guidelines from the AAOS.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period 06/03/2011

End Date of Comment Period 07/18/2011

Start Date of Notice Period 09/02/2011

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:06/03/2011

Start Date of Notice Period:09/02/2011 Original Effective Date 10/16/2011

LCR A2011-070

September 2011 Connection

Reason for Change