AIM (out-of-state / Federal BCBS) Arthroplasty (Joint Replacement) prior authorization requirements (2026)
What AIM (out-of-state / Federal BCBS) generally requires to approve Arthroplasty (Joint Replacement) (CPT 23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118), for commercial plans. Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Arthroplasty (Joint Replacement) (CPT 23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118).
Medical-necessity criteria AIM (out-of-state / Federal BCBS) generally applies
Prior authorization via Carelon. Knee TKA (27447): at least 12 weeks failed conservative management (PT plus at least one complementary therapy) — waived only if Kellgren-Lawrence grade 4 — with imaging showing KL grade 3-4 or diffuse Outerbridge III-IV and pain at least 3/10 limiting ADLs. Hip THA (27130): at least 12 weeks conservative management (waived if grade-4 imaging) with KL 3-4 / Tonnis grade 3. Shoulder TSA (23472): marked glenohumeral joint-space narrowing plus a degenerative finding, pain at least 3/10 for at least 6 months, intact deltoid/adequate bone stock, at least 6 weeks conservative care. Advisories: BMI 40+ pursue weight reduction first; HbA1c 8% or less for diabetics; tobacco abstinence at least 6 weeks pre-op. Carelon Joint Surgery MSK02-1125.1.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Arthroplasty (Joint Replacement). Confirm the covered diagnosis list against the current AIM (out-of-state / Federal BCBS) policy.
How to submit
- Method: Carelon ProviderPortal
- Portal: Carelon Medical Benefits Management
Sources & verification
- BindingSource — Carelon Clinical Appropriateness Guidelines — Joint Surgery (MSK02-1125.1) · effective 2025-11-15.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-26.
Frequently asked questions
Does AIM (out-of-state / Federal BCBS) require prior authorization for Arthroplasty (Joint Replacement)?
Yes. AIM (out-of-state / Federal BCBS) generally requires prior authorization for Arthroplasty (Joint Replacement) (CPT 23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25441, 25442, 25443, 25444, 25445, 25446, 25449, 26530, 26531, 26535, 26536, 27120, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27091, 27488, S2118).
What does AIM (out-of-state / Federal BCBS) require to approve Arthroplasty (Joint Replacement)?
Prior authorization via Carelon. Knee TKA (27447): at least 12 weeks failed conservative management (PT plus at least one complementary therapy) — waived only if Kellgren-Lawrence grade 4 — with imaging showing KL grade 3-4 or diffuse Outerbridge III-IV and pain at least 3/10 limiting ADLs. Hip THA (27130): at least 12 weeks conservative management (waived if grade-4 imaging) with KL 3-4 / Tonnis … Always confirm against the current AIM (out-of-state / Federal BCBS) policy.
How long does a AIM (out-of-state / Federal BCBS) prior authorization take?
Turnaround varies by plan and submission method. Check the AIM (out-of-state / Federal BCBS) portal for current timeframes.
Submitting Arthroplasty (Joint Replacement) to AIM (out-of-state / Federal BCBS)?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.