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LCD L36039: Total Joint Arthroplasty

LCD L36039, Total Joint Arthroplasty, is the Local Coverage Determination that Wellpoint Federal applies to claims from 13 states (CT, DN, IL, MA, ME, MN, NH, NY and others), effective 2026-04-01 and first in force 2015-12-01. The policy text runs 1,003 words, and its billing and coding article A57428 lists 1 ICD-10-CM codes that support medical necessity for 8 procedure codes. 3 other contractors publish a policy with the same title, so the criteria that apply depend on where the service is furnished.

QuickIntell editorial content · Legacy registry date · Review not verified

Data effective
Data currency: Medicare Coverage Database LCD export release of September 24, 2026 (effective September 20, 2026). Next CMS release: weekly (Thursdays) for the MCD.
Contractor
Wellpoint Federal
States and territories
13
CT DN IL MA ME MN NH NY QN RI UN VT WI
Revision effective
2026-04-01
Original effective
2015-12-01
Policy text
1,003 words
Covered ICD-10 codes (articles)
1

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L36039
ContractContractorTypeStates
06101Wellpoint FederalMAC - Part AIL
06201Wellpoint FederalMAC - Part AMN
06301Wellpoint FederalMAC - Part AWI
06102Wellpoint FederalMAC - Part BIL
06202Wellpoint FederalMAC - Part BMN
06302Wellpoint FederalMAC - Part BWI
13101Wellpoint FederalA and B and HHH MACCT
13201Wellpoint FederalA and B and HHH MACNY
13102Wellpoint FederalA and B and HHH MACCT
13202Wellpoint FederalA and B and HHH MACDN
13282Wellpoint FederalA and B and HHH MACUN
13292Wellpoint FederalA and B and HHH MACQN
14411Wellpoint FederalA and B and HHH MACRI
14211Wellpoint FederalA and B and HHH MACMA
14311Wellpoint FederalA and B and HHH MACNH
14511Wellpoint FederalA and B and HHH MACVT
14111Wellpoint FederalA and B and HHH MACME
14112Wellpoint FederalA and B and HHH MACME
14212Wellpoint FederalA and B and HHH MACMA
14312Wellpoint FederalA and B and HHH MACNH
14512Wellpoint FederalA and B and HHH MACVT
14412Wellpoint FederalA and B and HHH MACRI

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57428 (Billing and Coding: Total Joint 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.

A57428: Billing and Coding: Total Joint Arthroplasty (Billing and Coding, effective 2026-04-01)

Covered ICD-10-CM codes
1
1 group
Non-covered ICD-10-CM codes
0
Procedure codes listed
8
Full article
cms.gov record
First 1 covered ICD-10-CM codes in A57428
ICD-10-CMDescription (FY2027)
XX000—

Procedure codes: 27130, 27132, 27134, 27137, 27138, 27447, 27486, 27487.

Coverage indications, limitations and medical necessity

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*:

• Advanced Joint disease and all of the following (a,b,c):

• The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI)*; and

• Pain or functional disability attributable to the advanced joint disease; and

• 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

• Failure of a previous osteotomy; or

• Distal femur fracture; or

• Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or

• Failure of previous unicompartmental knee replacement; or

• Avascular necrosis of the knee; or

• 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*:

• Advanced Joint disease and all of the following (a,b,c):

• The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI) *; and

• Pain or functional disability attributable to the advanced joint disease; and

• 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

• 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 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

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
2015-12-01
Current revision effective
2026-04-01
MCD version
13

The contractor lists one National Coverage Determination as related: NCD 220.2 Magnetic Resonance Imaging. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.

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 Wellpoint Federal hub lists every other active policy from the same contractor.

The same policy title at other contractors

Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.

L33456
Palmetto GBA · 7 states · revised 2023-06-15 · 1,197 covered codes
L39911
Wisconsin Physicians Service Insurance Corporation · 48 states · revised 2026-08-27 · 1,670 covered codes
L40232
CGS Administrators, LLC · 2 states · revised 2026-03-15 · 1,313 covered codes

Frequently asked questions

What does LCD L36039 cover?

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). 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 L36039 apply to?

Wellpoint Federal applies it to Medicare claims in CT, DN, IL, MA, ME, MN, NH, NY, QN, RI, UN, VT, WI. 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 L36039?

The companion billing and coding article A57428 lists 1 ICD-10-CM codes in 1 group that support medical necessity; the first 1 appear on this page and the complete list is in the article on cms.gov.

How do I appeal a denial under LCD L36039?

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.

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.