CommercialCoverageHigh impact
Hip Arthroplasty 7.01.96
Excellus BlueCross BlueShield·Orthopedics·Bone & Joints (Orthopedic)
Effective date
Feb 16, 2026
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their Hip Arthroplasty policy effective February 16, 2026, establishing specific medical necessity criteria for partial hip replacement, total hip replacement, and revision procedures. The policy defines detailed requirements including imaging findings, symptom duration, failed conservative management, and contraindications that billing teams must verify for coverage approval.
Action Required
Before February 16, 2026: Billing team must update prior authorization processes to verify all new medical necessity criteria for hip arthroplasty procedures. Create documentation checklists requiring: imaging confirmation (Tönnis Grade 2-3 for osteoarthritis, femoral head collapse for AVN), 3+ months of function-limiting pain, failed 3+ months conservative management, and absence of contraindications (active infection, vascular insufficiency, dialysis for total hip). Update encounter forms to prompt providers for required documentation elements. Claims not meeting these specific criteria will be denied.