Medicaid: Submission of medical documentation for surgery of hip and knee

Applies to CPT codes 27447, 27130 and 27132 for the indication of osteoarthritis

Effective Dec. 1, 2025, providers requesting prior authorization for total joint replacement codes 27447, 27130 and 27132 for UnitedHealthcare Community Plan members in certain states may need to submit additional documents. No new codes are being added to the prior authorization list. This expands the requirements rolled out to other UnitedHealthcare Community plans earlier this year.

This applies to the following states:

• Colorado
• Kansas (27447 only)
• New Jersey
• New Mexico
• Tennessee

Effective Jan. 1, 2026, this applies to the following states:

• Louisiana
• Nebraska
• North Carolina
• Ohio (27447 only)
• Pennsylvania

Summary of changes

• Surgery of the hip (Medical Records Documentation Used for Reviews: Medicaid)
  Medical notes documenting the following, when applicable:

1. Complete diagnostic interpretation of imaging findings including, at a minimum: 

a. Relevant clinical information 

b. Detailed report of imaging findings

c. Impression 

d. Specialty(ies) of the provider(s) who interpreted the images

-  In addition, upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal images.

• Surgery of the knee (Medical Records Documentation Used for Reviews: Medicaid)
  Medical notes documenting the following, when applicable:

1. Complete diagnostic interpretation of imaging findings including, at a minimum: 

a. Relevant clinical information 

b. Detailed report of imaging findings, including at least the following:

i. Documented closure of skeletal plates (age less than 18 years)

ii. Presence or absence of focal full-thickness articular cartilage defect

iii. Size and location of focal cartilage defect

iv. Outerbridge grade

v. Joint space and alignment

vi. Ligament tear location and grade

c. Impression 

d. Specialty(ies) of the provider(s) who interpreted the images

-  In addition, upon request we may require the specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal images.

Conservative care requirements remain unchanged

The following treatments and their associated timing and duration should be easily identifiable in the clinical documentation.

Treatment within the last year must include:

• NSAIDs or acetaminophen ≥ 3 weeks
  • For TJR Knee ≥ 1 intra-articular corticosteroid injection may be used in place of NSAIDs
• PT or home exercise ≥ 12 weeks
• Activity modification ≥ 12 weeks