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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 that 
 
Total Hip Arthroplasty (THA) (TKA) 
 
The hip joint is 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. Hip 
arthroplasty is most often performed due to symptoms arising from arthritis, osteonecrosis, malignancy, and 
degenerative conditions. The goal of hip arthroplasty is to relieve pain and improve or increase patient 
function.  
 
 
Total Hip Arthroplasty (THA) 
 
THA 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. Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or 
    3. Avascular necrosis (osteonecrosis of femoral head); or 
    4. Fracture of the femoral neck; or 
   5. Acetabular fracture; or 
  6. Non-union or failure of previous hip fracture surgery; or 
   7.  Mal-union of acetabular or proximal femur fracture 
 
 
*See Documentation Requirements in the attached Billing and Coding Article for additional information.  
Replacement/Revision Hip Arthroplasty 
 
Replacement/Revision knee arthroplasty is considered reasonable and necessary for individuals with one or 
more of the following*: 
 
    Loosening 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 not amenable to conservative management; or 
    Progressive or substantial bone loss; or 
    Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; or 
    Clinically significant audible noise; or 
    Adverse local tissue reaction. 
 
 
*See Documentation Requirements in the attached Billing and Coding Article for additional information. 
 
Bilateral Surgery 
 
When bilateral TKA or bilateral THA is performed, the criteria listed above and documentation requirements 
below apply to the each joint upon which surgery is performed. 
 
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.