Orthopedics Prior Authorization and Denial Guide

Prior authorization requirements, denial patterns, and appeal strategies for musculoskeletal services, grounded in UHC Coverage Determination Guidelines, Aetna Clinical Policy Bulletins, Cigna Medical Coverage Policies, eviCore Musculoskeletal Clinical Guidelines, and AIM Specialty Health orthopedic criteria. Orthopedic surgery generates denial rates of 8–13% — among the highest of any specialty — due to high prior authorization burden for joint replacement, spine surgery, and arthroscopy.

Total joint replacement: Aetna, UHC, and Cigna all require prior authorization for total knee (CPT 27447) and total hip (CPT 27130) arthroplasty. Required documentation uniformly includes conservative treatment failure documentation (typically 3–6 months of physical therapy and/or NSAID trial), functional limitation assessment, X-ray or MRI imaging confirming the degree of degeneration, and BMI documentation. For patients with BMI above 40, most payers require documented weight management counseling or a higher evidentiary standard for medical necessity.

Spine surgery: lumbar fusion and cervical fusion require prior authorization from all major commercial payers and eviCore routes most spine surgery PA. Documentation requirements include 6 weeks of conservative care failure (physical therapy, NSAIDs, activity modification), imaging confirming the structural pathology, neurological examination findings, and for multi-level fusion, documentation of why the additional levels are medically necessary. Arthroscopic knee procedures (CPT 29880, 29881) face increasing scrutiny: most payers follow evidence reviews showing limited benefit for degenerative meniscal tears in older patients without mechanical symptoms.

• All specialty guides
• Appeal Letter Builder — orthopedic denial appeals
• Denial Decoder — CO-50 medical necessity decision tree