Orthopedics · Policy Library
Orthopedics coverage, at the criterion level.
Part of the Rubrica clinical policy library — the largest sourced collection in orthopedics. Every payor's coverage rule for orthopedic procedures: knee, hip, shoulder, elbow, and ankle arthroplasty; arthroscopy across every joint; rotator cuff repair; cartilage restoration; trauma; hand and upper extremity. Each record links to the policy of record and carries the verbatim criteria text.
Free with practitioner sign-in — magic-link email auth, no credit card.
Built for orthopedic surgeons, sports-medicine specialists, ASC operators, and the prior-auth coordinators running their practices. We track every Medicare LCD, every commercial medical policy, every Carelon and eviCore guideline, and every BCBS regional rule that touches the orthopedic catalog.
Top procedures by payor coverage
Eight procedures with the broadest payor coverage in this specialty. Click through any of them in the live app for the full coverage breakdown.
| CPT | Procedure | Coverage breadth |
|---|---|---|
20526 | Carpal Tunnel Injection | 98 payors |
20552 | Trigger Point Injection — 1 or 2 muscles | 98 payors |
20610 | Major Joint Injection (without US/Fluoro) | 98 payors |
20611 | Major Joint Injection (with US) | 98 payors |
J7321 | Supartz / Hyalgan / VISCO-3 (HCPCS) | 86 payors |
20553 | Trigger Point Injection — 3+ muscles | 76 payors |
27447 | Total Knee Arthroplasty (TKA) | 65 payors |
27130 | Total Hip Arthroplasty (THA) | 65 payors |
Full catalog at /library — 142 procedures, 141 unique CPTs.
Payors tracked
Top 12 payors by number of rules in this specialty. Each rule is sourced to a specific policy document with last-reviewed date.
Plus 124 more payors. Full per-payor drill-down at #payor=<name>.
Coverage Q&A
Common prior-auth questions for this specialty. Each answer is grounded in a specific policy document; live decisions are available at rubricamedical.com/#app.
Total knee arthroplasty (CPT 27447)
Universal coverage with conservative care, imaging, BMI thresholds (varies by payor — some cap at 40, some 45, Cigna is more permissive), and Kellgren-Lawrence grade ≥3 documentation. ASC eligibility expanded under CMS-1834-FC effective 2026-01-01 for revision TKA.
Knee arthroscopy with meniscectomy (CPT 29881)
Covered with failed conservative care; some payors require MRI-confirmed mechanical symptoms (locking, catching) before approving. Important not to confuse with degenerative meniscus tears, which are increasingly carved out.
Total hip arthroplasty (CPT 27130)
Covered with conservative care + imaging; Aetna CPB 0287 and Cigna CCP 0148 standard. ASC eligibility for THA confirmed for 2026.
Rotator cuff repair (CPT 23410 / 23412 / 23420)
Conservative care + imaging-confirmed full-thickness tear is the standard. Partial-thickness tears require additional documentation.
Shoulder arthroplasty — total / reverse (CPT 23472)
Covered with rotator cuff status + glenoid imaging documentation. Reverse arthroplasty (specific subset) covered with cuff arthropathy criteria.
How we encode coverage
Every record is keyed by payor + CPT + region, sourced to a public policy
document, dated by last-reviewed date, and tagged with verbatim source quotes
where available. Records older than 18 months are flagged stale; records that
couldn't be authoritatively confirmed are flagged needs_verification
and surfaced behind a warning.
The decision engine compares clinical context against criteria sub-objects — conservative care, imaging concordance, prior-procedure documentation, and repeat-procedure thresholds — and returns a likelihood plus a 0–100 denial-risk score with the top three drivers. Read the full methodology at /methodology.
Run a real check.
Pick a payor, enter the clinical context, get a sourced answer with denial risk and the missing documentation list — in seconds.
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