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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say Total Knee Arthroplasty (TKA) 
 
The knee joint 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 
normally covered with articular cartilage and are bathed in synovial fluid. The most common reason for knee 
arthroplasty is arthritis of the knee joint. Arthritis may cause pain, stiffness, or other symptoms which limit 
normal activities such as walking, squatting, and climbing stairs. Additional indications for knee arthroplasty 
include osteonecrosis, malignancy, and other degenerative conditions. The goal of knee arthroplasty is to 
relieve pain and improve or increase patient function. 
 
Indications: 
 
Total Knee Arthroplasty (TKA) 
 
TKA is considered reasonable and necessary for individuals with one or more of the following*: 
 
    1. Advanced Joint disease and all of the following (a,b,c): 
        a. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI)*; 
and 
       b. Pain or functional disability attributable to the advanced joint disease; and 
       c. Unsuccessful non-surgical medical management*, when appropriate, and attempted for a minimum of 3 
months. (When non-surgical medical management is not appropriate, the medical record must clearly document 
the basis for that conclusion); 
        or 
    2. Failure of a previous osteotomy; or 
    3. Distal femur fracture; or 
    4. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or 
   5. Failure of previous unicompartmental knee replacement; or 
   6. Avascular necrosis of the knee; or 
    7. Proximal tibia fracture 
 
 
 *See Documentation Requirements in the attached Billing and Coding Article for additional information. 
 
Replacement/Revision Knee Arthroplasty 
 
Replacement/Revision knee arthroplasty is considered reasonable and necessary for individuals with one or 
more of the following*: 
 
    Loosening of one or more component; or 
    Fracture or mechanical failure of one or more components, or 
    Infection, or 
    Periprosthetic fracture of distal femur, proximal tibia or patella, or 
    Progressive or substantial periprosthetic bone loss, or 
    Bearing surface wear with symptomatic synovitis, or 
    Implant or knee misalignment, or 
    Knee stiffness/arthrofibrosis, or 
    Tibiofemoral instability, or 
    Extensor mechanism instability 
 
*See Documentation Requirements in the attached Billing and Coding Article for additional information. 
 
Limitations 
 
TKA or THA is not considered reasonable or necessary when none of the criteria above are met. 
 
TKA or THA is not considered reasonable or necessary when one or more of the following contraindications 
are present: 
 
    Active infection of the hip or knee joint or active systemic bacteremia; and/or 
    Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned 
surgical site of the hip or knee; and/or 
    Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral 
neck fracture 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Total Joint Arthroplasty 
(L36039). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.