Anthem/Elevance Health Total Knee Arthroplasty prior authorization requirements (2026)
What Anthem/Elevance Health generally requires to approve Total Knee Arthroplasty (CPT 27447), for Commercial plans. Yes. Anthem/Elevance Health generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria Anthem/Elevance Health generally applies
Patient must meet ALL: (1) Severe knee OA (K-L Grade 3–4) on weight-bearing films or other disabling pathology; (2) Failure of ≥3 months structured conservative care: supervised PT (≥6 sessions with documented exercise program), NSAIDs, AND ≥1 corticosteroid injection; (3) Functional impairment by validated scores: KOOS Pain <40 or WOMAC >50 or VAS ≥7/10; (4) BMI documented; optimization required if BMI >40; (5) Anthem clinical pathway completed — AIM/Carelon authorization may be required for plans using specialty UM. Verify at time of PA submission.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Total Knee Arthroplasty. Confirm the covered diagnosis list against the current Anthem/Elevance Health policy.
Commonly required documentation
- Weight-bearing X-rays
- PT records with specific session count and supervised exercise documentation
- KOOS or WOMAC scores
- injection records with response
- BMI
- surgeon evaluation
- AIM/Carelon authorization number if plan-routed
How to submit
- Portal: Availity / Anthem Provider Portal
- Typical turnaround: about 3 days
Sources & verification
- BindingSource — Clinical Appropriateness Guidelines — Joint Surgery (Anthem delegates MSK joint surgery to Carelon) (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.
Frequently asked questions
Does Anthem/Elevance Health require prior authorization for Total Knee Arthroplasty?
Yes. Anthem/Elevance Health generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does Anthem/Elevance Health require to approve Total Knee Arthroplasty?
Patient must meet ALL: (1) Severe knee OA (K-L Grade 3–4) on weight-bearing films or other disabling pathology; (2) Failure of ≥3 months structured conservative care: supervised PT (≥6 sessions with documented exercise program), NSAIDs, AND ≥1 corticosteroid injection; (3) Functional impairment by validated scores: KOOS Pain <40 or WOMAC >50 or VAS ≥7/10; (4) BMI documented; optimization required … Always confirm against the current Anthem/Elevance Health policy.
How long does a Anthem/Elevance Health prior authorization take?
Anthem/Elevance Health typically decides Total Knee Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Knee Arthroplasty to Anthem/Elevance Health?
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.