NY State Workers' Comp Arthroplasty (Joint Replacement) prior authorization requirements (2026)
What NY State Workers' Comp 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 workers_comp plans. Yes. NY State Workers' Comp 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 NY State Workers' Comp generally applies
Total KNEE arthroplasty ALWAYS requires prior authorization (NY WC 324.3 pre-auth list) even when MTG-consistent — criteria: age over 50, osteoarthritis on imaging, failed conservative care (Knee MTG Table 8). Total HIP arthroplasty is authorized when consistent with the Hip and Groin MTG (severe arthritis/osteonecrosis or insufficient response to non-operative care). Request via OnBoard.
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 NY State Workers' Comp policy.
How to submit
- Method: OnBoard PAR
- Portal: NY WCB OnBoard
Sources & verification
- BindingSource — NY WCB Knee Injury Medical Treatment Guidelines · effective 2022-05-02.View
Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-06-25.
Frequently asked questions
Does NY State Workers' Comp require prior authorization for Arthroplasty (Joint Replacement)?
Yes. NY State Workers' Comp 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 NY State Workers' Comp require to approve Arthroplasty (Joint Replacement)?
Total KNEE arthroplasty ALWAYS requires prior authorization (NY WC 324.3 pre-auth list) even when MTG-consistent — criteria: age over 50, osteoarthritis on imaging, failed conservative care (Knee MTG Table 8). Total HIP arthroplasty is authorized when consistent with the Hip and Groin MTG (severe arthritis/osteonecrosis or insufficient response to non-operative care). Request via OnBoard. Always confirm against the current NY State Workers' Comp policy.
How long does a NY State Workers' Comp prior authorization take?
Turnaround varies by plan and submission method. Check the NY State Workers' Comp portal for current timeframes.
Submitting Arthroplasty (Joint Replacement) to NY State Workers' Comp?
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.