Medicare (CMS LCD/NCD) Total Knee Arthroplasty prior authorization requirements (2026)
What Medicare (CMS LCD/NCD) generally requires to approve Total Knee Arthroplasty (CPT 27447), for Medicare plans. Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria Medicare (CMS LCD/NCD) generally applies
Covered when advanced knee joint disease is documented on imaging (osteoarthritis with joint-space narrowing, deformity, or destructive disease) AND the patient has disabling pain and functional limitation that has failed at least ~3 months of conservative management (NSAIDs/analgesics, activity modification, physical therapy, and/or intra-articular injections). The record must specify the conservative treatments tried, their duration, and outcomes. Contraindicated with active local knee or systemic infection.
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 Medicare (CMS LCD/NCD) policy.
Sources & verification
Source: CMS LCD Total Knee Arthroplasty (L36575) and Major Joint Replacement Hip/Knee (L36007/L33618). Last verified 2026-06-10.
Frequently asked questions
Does Medicare (CMS LCD/NCD) require prior authorization for Total Knee Arthroplasty?
Yes. Medicare (CMS LCD/NCD) generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does Medicare (CMS LCD/NCD) require to approve Total Knee Arthroplasty?
Covered when advanced knee joint disease is documented on imaging (osteoarthritis with joint-space narrowing, deformity, or destructive disease) AND the patient has disabling pain and functional limitation that has failed at least ~3 months of conservative management (NSAIDs/analgesics, activity modification, physical therapy, and/or intra-articular injections). The record must specify the conserv… Always confirm against the current Medicare (CMS LCD/NCD) policy.
How long does a Medicare (CMS LCD/NCD) prior authorization take?
Turnaround varies by plan and submission method. Check the Medicare (CMS LCD/NCD) portal for current timeframes.
Submitting Total Knee Arthroplasty to Medicare (CMS LCD/NCD)?
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.