Cigna Total Knee Arthroplasty prior authorization requirements (2026)
What Cigna generally requires to approve Total Knee Arthroplasty (CPT 27447), for PPO, HMO plans. Yes. Cigna generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria Cigna generally applies
Per Cigna CCP 0178: Symptomatic knee OA with radiographic evidence (Kellgren-Lawrence grade 3-4, joint space narrowing, osteophytes); failure of ≥3 months conservative therapy including 6-12 weeks supervised PT, NSAIDs/analgesics, activity modification, and intra-articular injections; pain/functional impairment limiting ADLs; BMI documented (BMI >40 may require optimization); age and comorbidity assessment.
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 Cigna policy.
Commonly required documentation
- H&P, orthopedic consult notes, knee X-ray report (weight-bearing AP/lateral), documented conservative care (PT notes, injection records, medication trial), BMI/weight, functional assessment (WOMAC/KOOS), surgical plan, CPT/ICD-10 codes
How to submit
- Method: portal
- Portal: Cigna for Health Care Professionals
- Typical turnaround: about 5 days
Source
PA required for both in-network and out-of-network; OON covered at lower benefit. Cigna uses internal CCPs, not Carelon. Last verified 2026-05-18.
Frequently asked questions
Does Cigna require prior authorization for Total Knee Arthroplasty?
Yes. Cigna generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does Cigna require to approve Total Knee Arthroplasty?
Per Cigna CCP 0178: Symptomatic knee OA with radiographic evidence (Kellgren-Lawrence grade 3-4, joint space narrowing, osteophytes); failure of ≥3 months conservative therapy including 6-12 weeks supervised PT, NSAIDs/analgesics, activity modification, and intra-articular injections; pain/functional impairment limiting ADLs; BMI documented (BMI >40 may require optimization); age and comorbidity a… Always confirm against the current Cigna policy.
How long does a Cigna prior authorization take?
Cigna typically decides Total Knee Arthroplasty requests in about 5 days. Timeframes vary; check the payer portal.
Submitting Total Knee Arthroplasty to Cigna?
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.