Humana Total Knee Arthroplasty prior authorization requirements (2026)
What Humana generally requires to approve Total Knee Arthroplasty (CPT 27447), for Commercial plans. Yes. Humana generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria Humana generally applies
Patient must meet ALL: (1) Radiographic confirmation of knee OA (K-L Grade 3–4 on weight-bearing films) or other disabling pathology (AVN, post-traumatic); (2) Failure of ≥3 months conservative care: structured PT (≥6 sessions), NSAID/analgesic trial, and ≥1 corticosteroid injection; (3) Significant functional impairment (KOOS or WOMAC in severe range, or VAS ≥7/10 at multiple visits); (4) BMI documented — Humana requires weight management discussion if BMI >40; (5) Post-operative rehabilitation plan documented; (6) Cohere Health clinical pathway completed if applicable to member plan
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 Humana policy.
Commonly required documentation
- Weight-bearing AP, lateral, sunrise knee X-rays
- PT records with session count
- KOOS or WOMAC functional scores
- injection documentation (date, response)
- BMI
- post-op rehab plan
- Cohere Health authorization number if applicable
- surgeon operative note
How to submit
- Portal: Humana Provider Portal / Availity
- Typical turnaround: about 3 days
Source
Many Humana commercial plans route MSK PA through Cohere Health — check member ID card. Medicare Advantage: strict CMS-aligned criteria apply. Bilateral procedures require separate PA. Call 1-800-523-0023 to verify if Cohere routing applies.
Frequently asked questions
Does Humana require prior authorization for Total Knee Arthroplasty?
Yes. Humana generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does Humana require to approve Total Knee Arthroplasty?
Patient must meet ALL: (1) Radiographic confirmation of knee OA (K-L Grade 3–4 on weight-bearing films) or other disabling pathology (AVN, post-traumatic); (2) Failure of ≥3 months conservative care: structured PT (≥6 sessions), NSAID/analgesic trial, and ≥1 corticosteroid injection; (3) Significant functional impairment (KOOS or WOMAC in severe range, or VAS ≥7/10 at multiple visits); (4) BMI doc… Always confirm against the current Humana policy.
How long does a Humana prior authorization take?
Humana typically decides Total Knee Arthroplasty requests in about 3 days. Timeframes vary; check the payer portal.
Submitting Total Knee Arthroplasty to Humana?
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.