eviCore Total Knee Arthroplasty prior authorization requirements (2026)
What eviCore generally requires to approve Total Knee Arthroplasty (CPT 27447), for Commercial plans. Yes. eviCore generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria eviCore generally applies
Patient must meet ALL: (1) Severe osteoarthritis confirmed on weight-bearing X-rays (Kellgren-Lawrence Grade 3–4 joint space narrowing); (2) Failure of ≥3 months documented conservative treatment including PT (≥6 supervised sessions), NSAIDs or analgesics, AND at least one corticosteroid or hyaluronic acid injection; (3) Significant functional limitation documented by objective scores (KOOS or WOMAC in severe range, or VAS pain ≥7/10); (4) BMI documented — if BMI >40, documentation of surgical risk assessment or weight management attempt required; (5) No active joint infection, untreated DVT, or significant medical contraindications to surgery
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 eviCore policy.
Commonly required documentation
- Weight-bearing AP/lateral/sunrise knee X-rays with radiologist or surgeon interpretation
- PT records with visit dates and supervised session count
- documented pain scores (VAS or NRS) at multiple visits
- KOOS or WOMAC functional scores
- documentation of all conservative treatments attempted with dates
- BMI
- complete surgeon evaluation note
- operative risk clearance if BMI >40 or significant comorbidities
How to submit
- Portal: eviCore Connect
- Typical turnaround: about 3 days
Source
eviCore uses strict conservative care documentation requirements. Peer-to-peer available within 24 hours of denial. Cases with BMI >40 may be referred for additional medical review. Bilateral procedures require separate authorization.
Frequently asked questions
Does eviCore require prior authorization for Total Knee Arthroplasty?
Yes. eviCore generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does eviCore require to approve Total Knee Arthroplasty?
Patient must meet ALL: (1) Severe osteoarthritis confirmed on weight-bearing X-rays (Kellgren-Lawrence Grade 3–4 joint space narrowing); (2) Failure of ≥3 months documented conservative treatment including PT (≥6 supervised sessions), NSAIDs or analgesics, AND at least one corticosteroid or hyaluronic acid injection; (3) Significant functional limitation documented by objective scores (KOOS or WOM… Always confirm against the current eviCore policy.
How long does a eviCore prior authorization take?
eviCore typically decides Total Knee Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Knee Arthroplasty 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.