Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57683 (Billing and Coding: Total Hip Arthroplasty) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57683: Billing and Coding: Total Hip Arthroplasty (Billing and Coding, effective 2025-11-06)
- Covered ICD-10-CM codes
- 994
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 5
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C40.21 | — |
| C40.22 | — |
| C47.21 | — |
| C47.22 | — |
| C49.21 | — |
| C49.22 | — |
| D16.21 | — |
| D16.22 | — |
| D21.21 | — |
| D21.22 | — |
| L40.50 | — |
| L40.52 | — |
| L40.53 | — |
| L40.54 | — |
| L40.59 | — |
| M05.051 | — |
| M05.052 | — |
| M05.09 | — |
| M05.451 | — |
| M05.452 | — |
| M05.49 | — |
| M05.551 | — |
| M05.552 | — |
| M05.59 | — |
Procedure codes: 27130, 27132, 27134, 27137, 27138.
Coverage indications, limitations and medical necessity
Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The hip is a large weight bearing joint 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.
Arthritis causes a severe limitation in the activities of daily living (ADLs), including difficulty with walking, squatting, and climbing stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for a long time.
Total hip replacement surgery is most often performed due to severe pain caused by osteoarthritis (degenerative arthritis) of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also possible causes for hip replacement surgery. The use of THR in patients with malignancy must be weighed against considerations of life expectancy and possible alternative procedures to relieve pain. The pain from the damaged joint usually limits activities of daily living, such as walking, bathing and cooking. The pain can also cause disruption of sleep due to the inability to lie on the hip while in bed. Pain relief not achieved by taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as physical therapy, activity modification and (in some patients) assistive device use are reasons for proceeding with a total hip replacement. The goal of total hip replacement surgery is to relieve pain and improve or increase patient function. Occasionally, there may be a need to perform a reoperation on a previous total hip. This is often referred to as a revision total hip. Circumstances that lead to the need for a revision total hip are continued disabling pain, continued decline in function which can be attributed to failure of the primary joint replacement. Failure can be due to infection involving the joint, substantial bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components and wear of the prosthetic components.
Total Hip Arthroplasty (THA)
Noridian will consider total hip replacement surgery medically necessary in the following circumstances:
Advanced joint disease demonstrated by:
• Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, avascular necrosis); AND
• Pain that cannot be adequately controlled despite optimal conservative treatment or functional disability from injury due to trauma or arthritis of the joint; AND
• If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the pre-procedure medical record. (If conservative therapy is not appropriate, the medical record must clearly document the rationale for why such approach is not reasonable). Non-surgical medical management is usually but not always implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically appropriate for the patient’s current episode of care typically includes one or more of the following:
• anti-inflammatory medications or analgesics, or
• flexibility and muscle strengthening exercises, or
• supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], or
• assistive device use, or
• weight reduction as appropriate, or
• therapeutic injections into the hip as appropriate.
In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or significant disabling interference with activities of daily living, the surgeon may determine that nonsurgical medical management would be ineffective or counterproductive and that the best treatment option, after explaining the risks, is surgical. If medical management is deemed appropriate, the medical record should indicate the rationale for and the circumstances under which this is the case.
• Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or
• Avascular necrosis (osteonecrosis of femoral head); or
• Fracture of the femoral neck; or
• Acetabular fracture; or
• Non-union or failure of previous hip fracture surgery; or
• Mal-union of acetabular or proximal femur fracture
*See the associated Billing and Coding article (linked below) for Documentation Requirements.
Indications for Replacement/Revision of Total Hip Arthroplasty
• 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
Limitations
Noridian will not consider a total hip replacement medically necessary when the following contraindications are present:
• Active infection of the hip joint or active systemic bacteremia
• Active urinary tract or dental infection
• Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip.
• Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture
The following conditions are relative contraindications to total hip replacement and if such surgery is performed in the presence of these conditions, it is expected that the rationale for proceeding with the surgery under such circumstances is clearly documented in the medical record:
• Absence or relative insufficiency of abductor musculature
• Any process that is rapidly destroying bone
• Neurotrophic arthritis
This local coverage determination (LCD) is only addressing medical necessity criteria for performing total hip replacement surgery.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2025-11-06
- Last reviewed by the contractor
- 2021-03-02
- MCD version
- 33
- Derived from
- L33494
Other related documents: A55072 (Response to Comments), A55076 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L34163 cover?
Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The hip is a large weight bearing joint made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L34163 apply to?
Noridian Healthcare Solutions, LLC applies it to Medicare claims in AK, AS, AZ, CA, CNMI, GU, HI, ID, MT, ND, NF, NV, OR, SD, SF, UT, WA, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L34163?
The companion billing and coding article A57683 lists 994 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34163?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.