WellSense Health Plan Total Knee Arthroplasty prior authorization requirements (2026)
What WellSense Health Plan generally requires to approve Total Knee Arthroplasty (CPT 27447), for MassHealth, Individual/ConnectorCare, Medicare plans. Yes. WellSense Health Plan generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
Medical-necessity criteria WellSense Health Plan generally applies
Prior authorization required; delegated to eviCore (musculoskeletal program), which manages joint surgery including large-joint replacement. Reviewed against eviCore MSK clinical guidelines. Confirm CPT 27447 on the current eviCore WellSense joint code list per member.
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 WellSense Health Plan policy.
Commonly required documentation
- Office notes documenting pain and functional limitation, conservative-care history, and radiographs per eviCore MSK criteria.
How to submit
- Method: eviCore (844-725-4448 prompt 3, fax 855-774-1319)
- Portal: eviCore healthcare
Source
Source: WellSense 2026 MA Provider Manual + eviCore MSK program. TKA governed by the eviCore joint/MSK program. Last verified 2026-06-17.
Frequently asked questions
Does WellSense Health Plan require prior authorization for Total Knee Arthroplasty?
Yes. WellSense Health Plan generally requires prior authorization for Total Knee Arthroplasty (CPT 27447).
What does WellSense Health Plan require to approve Total Knee Arthroplasty?
Prior authorization required; delegated to eviCore (musculoskeletal program), which manages joint surgery including large-joint replacement. Reviewed against eviCore MSK clinical guidelines. Confirm CPT 27447 on the current eviCore WellSense joint code list per member. Always confirm against the current WellSense Health Plan policy.
How long does a WellSense Health Plan prior authorization take?
Turnaround varies by plan and submission method. Check the WellSense Health Plan portal for current timeframes.
Submitting Total Knee Arthroplasty to WellSense Health Plan?
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.