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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): Indications: Noridian will consider total knee replacement surgery medically necessary in the following circumstances:  Advanced joint disease demonstrated by: Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be performed) 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  If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable). Non-surgical medical management is usually but not always implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically appropriate for the patient's current episode of care typically includes one or more of the following: anti-inflammatory medications or analgesics, or flexibility and muscle strengthening exercises, or supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], or assistive device use, or weight reduction as appropriate, or therapeutic injections into the knee as appropriate.  In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or significant disabling interference with activities of daily living, the surgeon may determine that nonsurgical medical management would be ineffective or counterproductive, and that the best treatment option, after explaining the risks, is surgical. If medical management is deemed inappropriate, the medical record should indicate the rationale for and circumstances under which this is the case.   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  *See the associated Billing and Coding article (linked below) for Documentation Requirements.  Indications for Replacement/Revision of Total Knee Arthroplasty  Loosening of one or more components, or Fracture or mechanical failure of one or more component, or Infection, or Treatment of periprosthetic fracture of distal femur, proximal tibia or patella, or Progressive or substantial periprosthetic bone loss, or Bearing surface wear leading to symptomatic synovitis, or Implant or knee misalignment, or Knee stiffness/arthrofibrosis, or Tibiofemoral instability, or Extensor mechanism instability  Limitations  Noridian will not consider a total knee replacement medically necessary when the following contraindications are present: Active infection of the knee joint or active systemic bacteremia Active urinary tract or dental infection Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the knee Rapidly progressive neurological disease  The following conditions are relative contraindications to total knee replacement and if such surgery is performed in the presence of these conditions, it is expected that the rationale for proceeding with the surgery under such circumstances is clearly documented in the medical record: Insufficiency of extensor mechanism/quadriceps Any process that is rapidly destroying bone Neurotrophic arthritis  This local coverage determination (LCD) is only addressing medical necessity criteria for performing total 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. You can find this information in Medicare's Local Coverage Determination (LCD): Total Knee Arthroplasty (L36577).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.