**Abstract:**  
Joint replacement surgery, also known as arthroplasty, has proved to be an
important medical advancement. Arthroplasty surgery is most commonly performed
for diseases which affect the function of the hip joint and knee joint, but is
also performed on ankles, shoulders, and phalanges. In addition, the
arthroplasty may be total (involving the entire joint) or partial (involving
less than the entire joint).  
  
**Note:** This local coverage determination (LCD) only addresses total hip and
knee replacement surgery. 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.  
  
 ** _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.  
  
 ** _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.  
  
**_Revision Arthroplasty_**  
  
Revision arthroplasty is performed on an individual who has had a prior hip or
knee arthroplasty. Revision arthroplasty may be needed when pain or other
symptoms occur as a result of failure of the prior surgery. Failure may occur
as a result of infection of the joint, bone loss in the structures supporting
the prosthesis, fracture, aseptic loosening of the components, wear of the
prosthetic components, and for other reasons.  
  
**_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):   

    1. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI)*; and
    2. Pain or functional disability attributable to the advanced joint disease; and
    3. 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.  
  
 **_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):   

    1. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI) *; and
    2. Pain or functional disability attributable to the advanced joint disease; and  
c

    3. 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