Carelon Arthroplasty (Joint Replacement) prior authorization requirements (2026)
What Carelon 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. Carelon 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 Carelon generally applies
For all joint arthroplasties: (1) Severe joint disease confirmed on imaging (arthritis Grades 3–4, AVN with collapse, post-traumatic destruction); (2) Conservative management failure over ≥3 months (PT, NSAIDs, activity modification, corticosteroid injection); (3) Documented significant functional impairment with validated outcome scores; (4) No contraindications to surgery (active infection, significant medical comorbidities without clearance); (5) Patient understands and accepts post-operative rehabilitation requirements
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 Carelon policy.
Commonly required documentation
- Imaging of affected joint
- conservative care documentation
- validated functional outcome scores
- surgeon evaluation with operative plan
- medical clearance if comorbidities present
How to submit
- Portal: Carelon Provider Portal
- Typical turnaround: about 3 days
Source
Carelon manages joint replacement PAs for many Anthem and BCBS plans. Validated outcome scores are required — collect KOOS, HOOS, ASES, or DASH depending on joint. Call Carelon at 1-866-569-6099 to confirm plan-specific requirements.
Frequently asked questions
Does Carelon require prior authorization for Arthroplasty (Joint Replacement)?
Yes. Carelon 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 Carelon require to approve Arthroplasty (Joint Replacement)?
For all joint arthroplasties: (1) Severe joint disease confirmed on imaging (arthritis Grades 3–4, AVN with collapse, post-traumatic destruction); (2) Conservative management failure over ≥3 months (PT, NSAIDs, activity modification, corticosteroid injection); (3) Documented significant functional impairment with validated outcome scores; (4) No contraindications to surgery (active infection, sign… Always confirm against the current Carelon policy.
How long does a Carelon prior authorization take?
Carelon typically decides Arthroplasty (Joint Replacement) requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Arthroplasty (Joint Replacement) to Carelon?
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.