eviCore Arthroplasty (Joint Replacement) prior authorization requirements (2026)
What eviCore 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. eviCore 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 eviCore generally applies
For all joint arthroplasties: (1) Radiographic confirmation of severe joint disease (arthritis Grade 3–4, avascular necrosis, or post-traumatic arthritis with significant joint destruction); (2) Documented failure of ≥3 months conservative management (PT, NSAIDs, weight management, corticosteroid injections where appropriate); (3) Functional impairment documented by validated outcome scores; (4) No active joint or systemic infection; (5) Surgical risk clearance if significant comorbidities
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 eviCore policy.
Commonly required documentation
- Weight-bearing X-rays of affected joint
- conservative care treatment records
- functional outcome documentation
- surgeon evaluation
- medical clearance if comorbidities present
How to submit
- Portal: eviCore Connect
- Typical turnaround: about 3 days
Source
Specific criteria vary by joint. Shoulder, elbow, ankle, and wrist arthroplasties have additional specific criteria. Revision arthroplasty requires prior operative reports.
Frequently asked questions
Does eviCore require prior authorization for Arthroplasty (Joint Replacement)?
Yes. eviCore 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 eviCore require to approve Arthroplasty (Joint Replacement)?
For all joint arthroplasties: (1) Radiographic confirmation of severe joint disease (arthritis Grade 3–4, avascular necrosis, or post-traumatic arthritis with significant joint destruction); (2) Documented failure of ≥3 months conservative management (PT, NSAIDs, weight management, corticosteroid injections where appropriate); (3) Functional impairment documented by validated outcome scores; (4) N… Always confirm against the current eviCore policy.
How long does a eviCore prior authorization take?
eviCore typically decides Arthroplasty (Joint Replacement) requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Arthroplasty (Joint Replacement) to eviCore?
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.