Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 15102 | CGS Administrators, LLC | MAC - Part B | KY |
| 15202 | CGS Administrators, LLC | MAC - Part B | OH |
| 15101 | CGS Administrators, LLC | MAC - Part A | KY |
| 15201 | CGS Administrators, LLC | MAC - Part A | OH |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A60250 (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.
A60250: Billing and Coding: Total Joint Arthroplasty (Billing and Coding, effective 2026-03-15)
- Covered ICD-10-CM codes
- 1313
- 2 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 13
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C40.21 | — |
| C40.22 | — |
| C47.21 | — |
| C47.22 | — |
| C49.20 | — |
| C49.21 | — |
| C49.22 | — |
| D16.21 | — |
| D16.22 | — |
| D21.21 | — |
| D21.22 | — |
| M05.451 | — |
| M05.452 | — |
| M05.461 | — |
| M05.462 | — |
| M05.551 | — |
| M05.552 | — |
| M05.561 | — |
| M05.562 | — |
| M05.59 | — |
| M05.751 | — |
| M05.752 | — |
| M05.761 | — |
| M05.762 | — |
Procedure codes: 0054T, 0055T, 20985, 27130, 27132, 27134, 27137, 27138, 27446, 27447, 27486, 27487, S2900 (Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure)).
Coverage indications, limitations and medical necessity
Total Knee Arthroplasty
Primary total knee arthroplasty is considered reasonable and medically necessary if all of the following criteria have been met (1,2,3,4 and 5):
1. Advanced joint disease; 1-4
• Osteoarthritis with joint destruction 1-4 OR
• Avascular necrosis (osteonecrosis) 5 OR
• Inflammatory arthritis when intractable to medical management 2 OR
• Traumatic with joint destruction (distal femur fracture, proximal tibia fracture) 6 OR
• Tumor (malignant and non-malignant) with joint destruction affecting the femur, proximal tibia, knee joint of adjacent soft tissues 2,7 OR
• Failed osteotomy or unicompartmental knee arthoplasty 8
2. Moderate to severe pain and loss of function using standardized pain and function scales* for assessment; 9
3. Radiographic findings demonstrating advanced arthritic changes; 1
• X-ray assessments consistent with advanced arthritic changes i.e. a score of ≥2 on the Kellgren–Lawrence scale, with scores ranging from 0 to 4 and a score of ≥2 indicating definite osteoarthritis 3,9 OR
• Alternative radiographic measures (such as MRI or CT) when conventional radiographs are not adequate.
4. A trial of at least 1 or more conservative therapy without improvement in pain and function typically for a duration of a minimum of 3 months. In exceptional circumstances when conservative therapy is determined to not be appropriate, rationale must be documented in the medical record; 10-12
5. Optimization of co-morbidities if applicable
• Documentation of smoking history, and counselling on the effect of smoking on healing. Treatment for smoking cessation and outcome of counselling, if applicable.
• For patients with diabetes documentation of counseling of risk and efforts to optimize medical management and reduce blood sugars if applicable
• For obesity, risk counseling and efforts for weight reduction to optimize outcomes documented.
Revision or replacement
Revision or replacement TKA will be considered medically necessary if:
1. Documentation as to the cause of the failure of the primary procedure (such as infection, aseptic loosening , periprosthetic fracture, instability, moderate to severe pain and loss of function using standardized pain and function scales for assessment, polyethylene wear, restriction of motion/arthrofibrosis, extensor mechanism insufficiency, implant failure, and allergy). 13
AND
2. Modifiable factors are addressed prior to surgical intervention.
Total Hip Arthroplasty
Primary total hip arthroplasty is considered reasonable and medically necessary if all of the following criteria have been met (1,2,3,4&5):
1. Advanced joint disease;
• Osteoarthritis with joint destruction 1-4 OR
• Avascular necrosis of the hip (osteonecrosis of femoral head) 14,15 OR
• Femoroacetabular impingement syndrome 16 OR
• Developmental hip dysplasia or childhood hip disorders 14 OR
• Fracture of the femoral neck 15 OR
• Non-union or failure of previous hip fracture or malunion of acetabular or proximal femur fracture 14 OR
• Malignancy of the joint involving the bones or soft tissue of the pelvis or proximal femur 14
• Acetabular fracture 14
2. Moderate to severe pain and loss of function using standardized pain and function scales* for assessment; 9
3. Radiographic findings demonstrating advanced arthritic changes; 1
• X-ray assessments consistent with advanced arthritic changes e., a score of ≥2 on the Kellgren–Lawrence scale, with scores ranging from 0 to 4 and a score of ≥2 indicating definite osteoarthritis; 3,9 OR
• Alternative radiographic measures (such as MRI) when conventional radiographs are not adequate
4. A trial of at least 1 or more conservative therapy without improvement in pain and function typically for a duration of a minimum of 3 months. In exceptional circumstances when conservative therapy is determined to not be appropriate, rationale must be documented in the medical record. 11,12
5. Optimization of co-morbidities if applicable
• Documentation of smoking history, and counselling on the effect of smoking on healing. Treatment for smoking cessation and outcome of counselling, if applicable.
• For patients with diabetes documentation of counseling of risk and efforts to optimize medical management and reduce blood sugars if applicable
• For obesity, risk counseling and efforts for weight reduction to optimize outcomes documented.
Revision or replacement
Revision or replacement THA will be considered medically necessary if:
1. Documentation as to the cause of the failure of the primary procedure (such as instability, aseptic loosening, osteolysis and/or wear, infection, periprosthetic fracture, implant fracture, failed bipolar, periprosthetic bone loss, fracture, mechanic failure, and dislocation) 17 AND
2. Modifiable factors are addressed prior to surgical intervention.
Limitations
TJA should not be performed in presence of:
• Local or systemic active infection
• Neuropathic arthritis
• Rapidly progressive neurological disease
• Skeletal immaturity
• Quadriplegia
• Permanent or irreversible muscle weakness in the absence of pain
Bilateral Surgery
When bilateral TKA or bilateral THA is performed, the criteria listed above and documentation requirements below apply to each joint upon which surgery is performed.
This local coverage determination (LCD) is only addressing medical necessity criteria for performing total knee and hip replacement surgery. The indications in this LCD are not to be applied for unicompartmental knee replacement surgery which is only contained to one compartment of the knee. However, failed previous unicompartmental joint replacement is an indication for performing TKA.
The devices/implants for total knee and total hip replacement surgeries are regulated by the FDA as medical devices. The devices used should be class II or class III devices that meet the requirements as outlined in the CFR, Title 21, Volume 8, Chapter I, Subchapter H, Part 888 Orthopedic Devices.
Definitions
Total Joint Arthroplasty (TJA) replacement of the joint with an endoprosthesis or implant.
Total Knee Arthroplasty (TKA) also referred to as total knee replacement is a surgical procedure in which the diseased articular surface of the knee is resected followed by resurfacing with prosthetic components. 2
Total hip Arthroplasty (THA) also referred to as hip replacement is a surgical procedure in which the diseased portion of the hip is resected followed by artificial components.
Conservative therapy- nonsurgical management which includes may physical therapy, non-steroidal anti-inflammatory drugs (NASIDS), braces, intraarticular injections, weight reduction, and smoking cessation. 9
Grading of Recommendations Assessment, Development and Evaluation (GRADE)- widely recognized system for assessing the quality of evidence and the strength of recommendations in healthcare. 18
*Scales 19
Standardized pain scales should be used for the evaluation. The specific scales are at the discretion of the provider but examples of standardized scales include but are not limited to:
• EuroQol-5 Dimension (EQ-5D)
• Hanover Functionality Status Questionnaire (FFbH)
• Harris Hip Score (HHS)
• Hip Disability and Osteoarthritis Outcome Score (HOOS)
• Hospital for Special Surgery Knee Score
• Insall Knee Score
• Knee Injury and Osteoarthritis Outcome Score (KOOS)
• Knee Society Score
• Numerical Rating Score (NRS)
• Oxford Knee questionnaires/ Oxford Hip Score
• Timed up-and-go test to assess
• Western Ontario and McMaster Universities (WOMAC) questionnaire
• Visual Analog Scale (VAS)
• 40-meter walk test, 30-second chair test, stair-climb test and six-minute walk test
Summary of evidence (opening)
Literature Search
A literature search was conducted using the following key words: total knee arthroplasty; total hip arthroplasty, total joint arthroplasty, unicompartmental knee arthroplasty, robotic-assisted, computer aided navigation, revision. The literature search was filtered to identify articles within 5-10 years, English language, full-text articles, clinical trials, and systematic reviews/meta-analyses (SR/MA). In general, improved health outcomes of interest include patient quality of life and function.
Evidence was analyzed to address the certainty of evidence that the change in outcome is due to the product being investigated and improves patients’ outcomes. Case reports, case series and retrospective reports were not reviewed for product coverage due to low certainty evidence but used as an adjunctive measure for other aspects pertinent to this subject. Review papers, editorials, cost analysis and unpublished reports were not included in the analysis.
Background
The contractor cites 76 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2026-03-15
- Current revision effective
- 2026-03-15
- MCD version
- 5
Other related documents: A60399 (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 CGS Administrators, LLC 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.
Frequently asked questions
What does LCD L40232 cover?
Primary total knee arthroplasty is considered reasonable and medically necessary if all of the following criteria have been met (1,2,3,4 and 5): 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 L40232 apply to?
CGS Administrators, LLC applies it to Medicare claims in KY, OH. 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 L40232?
The companion billing and coding article A60250 lists 1,313 ICD-10-CM codes in 2 groups 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 L40232?
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.