Sedgwick Total Knee Arthroplasty prior authorization requirements (2026)
What Sedgwick generally requires to approve Total Knee Arthroplasty (CPT 27447). Yes. Sedgwick generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria Sedgwick generally applies
Sedgwick follows ODG (Official Disability Guidelines) / MDGuidelines for WC UR. ALL required: (1) Work-related causation narrative from treating physician linking mechanism of injury to knee condition; (2) Radiographic confirmation of severe knee pathology; (3) ODG-compliant conservative care: WC PT per ODG duration guidelines, analgesics, ≥1 corticosteroid injection; (4) Functional Capacity Evaluation (FCE) if significant disability claimed; (5) Nurse case manager (NCM) must be notified — Sedgwick assigns NCM to complex surgical cases; (6) Employer/TPA authorization: Sedgwick acts as TPA — employer approval required for surgeries above plan threshold (typically >$10,000); (7) RTW/MMI projection
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 Sedgwick policy.
Commonly required documentation
- Treating physician causation statement
- complete medical records from date of injury
- diagnostic imaging
- WC PT records meeting ODG duration
- injection records
- FCE if performed
- NCM contact documentation
- employer/self-insured authorization
How to submit
- Portal: mySedgwick Provider Portal
- Typical turnaround: about 7 days
Source
Contact assigned Sedgwick claim rep FIRST — each claim has a dedicated adjuster who must be informed of surgical plan. NCM involvement is standard for all surgical cases. Sedgwick uses MDGuidelines (formerly ODG) — criteria must align. Call the claim-specific phone number on the injured worker's authorization card.
Frequently asked questions
Does Sedgwick require prior authorization for Total Knee Arthroplasty?
Yes. Sedgwick generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does Sedgwick require to approve Total Knee Arthroplasty?
Sedgwick follows ODG (Official Disability Guidelines) / MDGuidelines for WC UR. ALL required: (1) Work-related causation narrative from treating physician linking mechanism of injury to knee condition; (2) Radiographic confirmation of severe knee pathology; (3) ODG-compliant conservative care: WC PT per ODG duration guidelines, analgesics, ≥1 corticosteroid injection; (4) Functional Capacity Evalu… Always confirm against the current Sedgwick policy.
How long does a Sedgwick prior authorization take?
Sedgwick typically decides Total Knee Arthroplasty requests in about 7 days. Timeframes vary; check the payer portal.
Submitting Total Knee Arthroplasty to Sedgwick?
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.