MedicaidDocumentationHigh impact
Medicaid: Required documentation changes for hip and knee total joint replacements
UnitedHealthcare·AZ, CO, FL, HI, KS, LA, MD, MI, MO, NE, NJ, NM, NY, NC, OH, PA, RI, TN, TX, VA, WA, WI · Orthopedics·Prior authorization updates
Effective date
Dec 1, 2025
We identified it
Jan 12, 2026
Summary
UnitedHealthcare Community Plan (Medicaid) now requires enhanced medical documentation for prior authorization of total hip and knee joint replacement surgeries (CPT 27447, 27130, 27132) when performed for osteoarthritis. New requirements include detailed imaging reports with specific findings and provider specialties who interpreted images, rolling out across multiple states with different effective dates.
Action Required
By December 1, 2025: Billing team must update prior authorization submission processes for CPT codes 27447, 27130, and 27132 to include comprehensive imaging documentation with detailed reports, clinical findings, impressions, and interpreting provider specialties. Ensure conservative care documentation (NSAIDs ≥3 weeks, PT ≥12 weeks, activity modification ≥12 weeks) remains complete. Update submission checklists for affected states. Prior authorizations without complete documentation will be denied.