QualCare Arthroplasty (Joint Replacement) prior authorization requirements (2026)
What QualCare 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. QualCare 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 QualCare generally applies
Prior authorization via eviCore (Cigna MSK program). Total/partial knee replacement medically necessary when imaging shows severe osteoarthritis (Kellgren-Lawrence Grade IV radiographic, or Outerbridge Grade IV) or AVN, with function-limiting pain at least 3 months and failure of provider-directed non-surgical management for at least 3 months. Shoulder and hip arthroplasty governed by the parallel eviCore shoulder (CMM-315) and joint guidelines. Governed by eviCore CMM-311 (knee).
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 QualCare policy.
How to submit
- Method: eviCore portal
- Portal: eviCore by Evernorth (Cigna MSK/Spine)
Sources & verification
- BindingSource — Cigna CMM-311 Knee Replacement / Arthroplasty (CMM-311) · effective 2025-07-01.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 2026-06-26.
Frequently asked questions
Does QualCare require prior authorization for Arthroplasty (Joint Replacement)?
Yes. QualCare 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 QualCare require to approve Arthroplasty (Joint Replacement)?
Prior authorization via eviCore (Cigna MSK program). Total/partial knee replacement medically necessary when imaging shows severe osteoarthritis (Kellgren-Lawrence Grade IV radiographic, or Outerbridge Grade IV) or AVN, with function-limiting pain at least 3 months and failure of provider-directed non-surgical management for at least 3 months. Shoulder and hip arthroplasty governed by the parallel… Always confirm against the current QualCare policy.
How long does a QualCare prior authorization take?
Turnaround varies by plan and submission method. Check the QualCare portal for current timeframes.
Submitting Arthroplasty (Joint Replacement) to QualCare?
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.