Knee replacement and knee arthroscopy procedures will require prior authorization

Date: 08/06/19

There is an important change to our prior authorization (PA) requirements applicable to services rendered to MHS Health Wisconsin’s and Network Health’s BadgerCare Plus and SSI members. These changes are effective August 1, 2019.

Adding Prior Authorization

Knee replacement and knee arthroscopy procedures will require prior authorization (PA) effective August 1, 2019.  Based on a sample documentation review of these procedures within the last year, it was noted that medical necessity criteria (Interqual™) was not met due to lack of documentation showing conservative interventions prior to the procedures such as (but not limited to) a trial of physical therapy, joint injections, medication management, and activity modifications.  Requests for PA which do not meet Interqual™ criteria will be reviewed by an independent board-certified orthopedic surgeon.  The CPT codes which will require a PA are as follows:

Knee Replacement

27438 – 27447; 27486 – 27488

Knee Arthroscopy

29876 - 29877

Please submit your prior authorization requests with all pertinent documentation via our online tool at www.mhswi.com (go to “For Providers”, then “Provider Resources”, then “Prior Authorizations” or fax to 866-467-1316).  If you have questions or concerns about this change in policy, please contact the MHS Health Wisconsin Provider Inquiry Line at 1-800-222-9831. Thank you for partnering with us to provide the best care to our members, and for helping us transform the health of the community one person at a time.