Level of Care for Total Joint Replacement (Hip and Knee)

Commercial products (including Tufts Freedom Plan), Tufts Health Public Plans products

October 30, 2020  

Effective for dates of service on or after January 1, 2021, CMS will remove total joint arthroplasty procedures (hip and knee) from the Medicare inpatient-only list of procedures to allow for these procedures to be performed in an outpatient setting.

Both providers and members have recognized the benefits associated with procedures performed in the outpatient setting, and some providers are already doing this with same- or next-day discharge followed by outpatient physical therapy (PT), including PT at home.

Although total joint arthroplasty procedures (hip and knee) performed in the outpatient setting are appropriate, there is a select group of members for whom elective hip or knee arthroplasty may be more appropriately performed in the inpatient setting.

Refer to the Medical Necessity Guidelines for Inpatient Setting for Elective Total Joint Arthroplasty; Hip and Knee, which is available in the Resource Center on the public Provider website, effective January 1, 2021. Note: Tufts Health Plan will continue to allow elective total joint arthroplasty (hip and knee) procedures to be performed in the inpatient setting for certain groups of members when medical necessity criteria are met.

At this time, Tufts Health Plan will not require prior authorization for these procedures to be performed at the inpatient level of care. However, Tufts Health Plan strongly recommends that providers assess each patient’s individual clinical situation using these newly issued guidelines to determine the appropriate setting for performing the procedure.

The prior authorization requirement for total joint arthroplasty (hip and knee) procedures that are currently in place to determine medical necessity for the surgical procedure, regardless of level of care, will remain in place for Commercial products (including Tufts Health Freedom Plan) and Tufts Health Public Plans products. All such procedures are subject to National Imaging Associates' (NIA) prior authorization requirements.