Oscar Health Arthroplasty (Joint Replacement) prior authorization requirements (2026)
What Oscar Health 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. Oscar Health 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 Oscar Health generally applies
Prior authorization required via eviCore (CMM-311 Knee Replacement / CMM-314 Hip). Knee replacement: Kellgren-Lawrence grade IV or exposed subchondral bone; at least 3 months conservative care; if BMI over 40, failure of at least 6 months of provider-directed non-surgical management.
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 Oscar Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — Oscar — eviCore Musculoskeletal/Spine/Pain program.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 Oscar Health require prior authorization for Arthroplasty (Joint Replacement)?
Yes. Oscar Health 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 Oscar Health require to approve Arthroplasty (Joint Replacement)?
Prior authorization required via eviCore (CMM-311 Knee Replacement / CMM-314 Hip). Knee replacement: Kellgren-Lawrence grade IV or exposed subchondral bone; at least 3 months conservative care; if BMI over 40, failure of at least 6 months of provider-directed non-surgical management. Always confirm against the current Oscar Health policy.
How long does a Oscar Health prior authorization take?
Turnaround varies by plan and submission method. Check the Oscar Health portal for current timeframes.
Submitting Arthroplasty (Joint Replacement) to Oscar Health?
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.