UnitedHealthcare Total Knee Arthroplasty prior authorization requirements (2026)
What UnitedHealthcare generally requires to approve Total Knee Arthroplasty (CPT 27447), for Commercial plans. Yes. UnitedHealthcare generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria UnitedHealthcare generally applies
UnitedHealthcare reviews total knee replacement (Total Joint Replacement, Knee) against InterQual CP: Procedures criteria (policy 2026T0553II, Surgery of the Knee). Medical necessity centers on documented osteoarthritis with radiographic findings (UHC accepts 3 or more moderate-to-severe among joint-space narrowing, osteophyte formation, subchondral sclerosis, subchondral cysts, bony deformity, or cartilage loss) together with disabling pain (WOMAC pain domain greater than 40) and functional disability (WOMAC function domain greater than 40), after failed non-operative management. Specific conservative-care duration and BMI thresholds are adjudicated via InterQual.
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 UnitedHealthcare policy.
Source
Summarized from UnitedHealthcare Commercial and Individual Exchange Medical Policy Surgery of the Knee (2026T0553II, eff 2026-06-01). UHC adjudicates specific numeric thresholds via InterQual CP: Procedures. Source: View the source policy. Last verified 2026-06-13.
Frequently asked questions
Does UnitedHealthcare require prior authorization for Total Knee Arthroplasty?
Yes. UnitedHealthcare generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does UnitedHealthcare require to approve Total Knee Arthroplasty?
UnitedHealthcare reviews total knee replacement (Total Joint Replacement, Knee) against InterQual CP: Procedures criteria (policy 2026T0553II, Surgery of the Knee). Medical necessity centers on documented osteoarthritis with radiographic findings (UHC accepts 3 or more moderate-to-severe among joint-space narrowing, osteophyte formation, subchondral sclerosis, subchondral cysts, bony deformity, or… Always confirm against the current UnitedHealthcare policy.
How long does a UnitedHealthcare prior authorization take?
Turnaround varies by plan and submission method. Check the UnitedHealthcare portal for current timeframes.
Submitting Total Knee Arthroplasty to UnitedHealthcare?
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.