Hip Replacement Coverage and Pre-Approval: A Step-by-Step Patient Checklist

A hip replacement can change your life—less pain, better walking, better sleep, and a return to activities you’ve been avoiding. But many patients run into a frustrating obstacle right before surgery: the insurer says the pre-approval (also called prior authorization) is incomplete, needs more documentation, or does not meet medical necessity requirements. That can mean delays, rescheduling, or worst case, a last-minute cancellation.

The good news: most denials are preventable when you understand what insurers look for and you prepare the right “proof” early. In plain terms, insurers want to see a consistent story across your records:

• you have a condition that typically warrants hip replacement,
• your symptoms and daily function limits are significant,
• imaging confirms the joint damage, and
• reasonable nonsurgical treatment has been tried (or clearly documented as inappropriate).

Those themes show up across commercial insurer medical policies and Medicare contractor documentation guidance. ^[1]

This article gives you a practical, step-by-step patient checklist to reduce delays and help your surgeon’s office submit an approval request that matches the criteria insurers actually use.

Pre-approval is a medical necessity review, not just a scheduling formality. Your plan (or a utilization management vendor working for your plan) reviews your records to decide whether the procedure meets coverage rules and whether the documentation is complete.

A typical hip replacement request includes:

• the diagnosis and reason for surgery (such as osteoarthritis, avascular necrosis, inflammatory arthritis, or post-traumatic arthritis), ^[1]
• imaging proof (X-ray and sometimes magnetic resonance imaging or computed tomography), ^[1]
• symptoms and functional limitations (what you cannot do anymore), ^[1]
• documentation of nonsurgical treatment attempts (such as medications, supervised physical therapy, activity modification), ^[1]
• physical exam findings (for example, pain with passive range of motion, limited range of motion, antalgic gait), ^[1]
• and screening for contraindications (for example, active infection, open wound near the site). ^[1]

Important: pre-approval may involve more than one authorization. Some plans separately require authorization for:

• the surgeon’s procedure,
• the facility (hospital or surgery center),
• inpatient admission versus outpatient status,
• and sometimes post-acute rehabilitation.

That’s why you’ll see “approved” but still face scheduling issues if one piece is missing.

While details vary by insurer and plan type, the common approval framework looks like this:

Insurer policies list conditions such as osteoarthritis, rheumatoid arthritis, avascular necrosis, and post-traumatic arthritis as typical reasons for total hip replacement. ^[1]

Some policies also include tumor involvement, unstable fractures, severe impingement with advanced arthritis, and revision scenarios. ^[1]

This is where many denials happen—because the chart says “hip pain,” but does not clearly describe how it limits daily life.

Example of what reviewers want to see in records:

• pain that interferes with activities of daily living (bathing, dressing, toileting, cooking, getting in and out of chairs), ^[2]
• pain that increases with weight-bearing or initiation of activity, ^[2]
• reduced ability to walk meaningful distances (some criteria explicitly reference short-distance limits such as walking less than one-quarter mile). ^[3]

Insurers usually require X-ray evidence of advanced degenerative change or other qualifying pathology.

Medicare contractor guidance for hip arthroplasty documentation describes imaging support for hip arthritis using X-ray, magnetic resonance imaging, or computed tomography, and lists common imaging findings reviewers look for (subchondral cysts, sclerosis, periarticular osteophytes, joint subluxation, degree of joint space narrowing, avascular necrosis, or bone-on-bone). ^[2]

Commercial medical policies often list similar X-ray features (for example, joint space narrowing, osteophytes, sclerosis, and bone-on-bone articulation). ^[1]

Most plans expect a documented trial of nonsurgical care before elective hip replacement for degenerative arthritis. Examples of conservative treatment elements listed in commercial policy guidance include:

• anti-inflammatory medications or analgesics,
• activity modification,
• supervised physical therapy (which may include a home exercise program),
• weight reduction counseling as appropriate,
• use of assistive devices,
• injections (sometimes appropriate but not always required). ^[1]

Some plans specify timing thresholds. For example, one UnitedHealthcare update states conservative treatment within the last year should be easily identifiable in documentation and includes: anti-inflammatory medications or acetaminophen for at least 3 weeks, physical therapy or home exercise for at least 12 weeks, and activity modification for at least 12 weeks. ^[4]

Other utilization management criteria may use “at least three months” of provider-directed nonsurgical management for osteoarthritis-related hip replacement requests, with documented exceptions if nonsurgical management is inappropriate. ^[3]

Medical policies often want documentation of:

• limited range of motion,
• antalgic gait,
• and pain in the hip joint with passive range of motion. ^[1]

Even if you have severe imaging, a thin exam note can weaken the request.

Policies commonly list “do not proceed” scenarios such as active infection (local joint infection or systemic bacteremia), open wounds near the surgical site, certain severe neuromuscular issues, or other major concerns. ^[1]

Ask your insurer (or check your plan portal) and confirm:

• Is prior authorization required for total hip replacement?
• Does your plan require pre-approval for the facility and for inpatient admission?
• Do you need to use an in-network surgeon, hospital, anesthesiologist, and implant provider?
• Is there a specific medical policy your plan uses for “surgery of the hip”?

Why this matters: some insurers update documentation requirements (for example, requesting a complete diagnostic interpretation of imaging and sometimes the actual images). ^[4]

Patient tip: Write down the representative’s name, date, reference number, and exactly what they said.

Most approvals are won or lost on documentation completeness. Here is what you want collected and easy to send:

It should clearly include:

• diagnosis and reason for surgery (for example, osteoarthritis),
• how long symptoms have been present,
• failed nonsurgical treatments and duration,
• functional limits with real examples,
• physical exam findings (range of motion limits, gait, pain with passive motion),
• and the plan for total hip replacement.

Commercial policy criteria explicitly call for documentation of failed conservative therapy and exam findings like limited range of motion and antalgic gait. ^[1]

Aim to have:

• the radiology report and date,
• the impression section,
• and relevant details (joint space narrowing, osteophytes, sclerosis, bone-on-bone, and other key findings).

Some insurers specify that imaging documentation should include relevant clinical information, detailed findings, impression, and even the specialty of the interpreting provider, and they may request the actual diagnostic images. ^[4]

Medicare guidance also emphasizes that imaging should demonstrate specific arthritic changes or avascular necrosis findings. ^[2]

Collect records showing:

• medications tried (names, doses, dates, why stopped),
• supervised physical therapy notes (start/end dates, response),
• home exercise program instructions if used,
• activity modification attempts,
• assistive device use (cane, walker),
• injections if performed (date and response).

One commercial policy example lists these conservative elements directly, and notes injections may be appropriate but are not always required. ^[1]

If you are under a plan with specific minimum durations (for example, 12 weeks of physical therapy or home exercise), make sure the dates are obvious in the chart. ^[4]

This can come from the surgeon, primary care clinician, or physical therapist. Strong documentation uses specifics like:

• “unable to climb stairs without stopping,”
• “needs help putting on socks and shoes,”
• “wakes from hip pain nightly,”
• “cannot stand long enough to cook,”
• “walks only a few minutes before needing to sit.”

Medicare contractor guidance explicitly calls for pain or functional disability description in context, including how it interferes with activities of daily living or weight-bearing activities. ^[2]

Some criteria frameworks emphasize that modifiable medical and behavioral health issues should be optimized before surgery. ^[3]

This is also practical: if your insurer questions safety (for example, uncontrolled medical conditions), having preoperative clearance ready can prevent delays.

Insurers don’t just want “hip pain.” They want the key phrases that match their criteria. Examples of documentation language that aligns with published criteria:

• Function-limiting pain at short distances and the impact on activities of daily living and work demands. ^[3]
• Failure of provider-directed nonsurgical management for at least three months (or clearly documented reasons why it is inappropriate). ^[3]
• Radiographic evidence of advanced osteoarthritis (joint space narrowing, osteophytes, sclerosis, bone-on-bone). ^[1]
• Physical exam showing limited range of motion, antalgic gait, and pain with passive range of motion. ^[1]

If your clinician documentation is vague, it can be worth messaging the office and asking them to include these specifics in the clinical note before submission.

Before you lock in the surgical date, ask the surgeon’s office for:

• the authorization reference number,
• the approved procedure code(s),
• the approved facility,
• the approved date range,
• and whether inpatient admission is approved (if applicable).

If your plan uses a portal submission process, incomplete submissions can delay review or result in denial, which is why payer forms stress submitting all requested medical records. ^[5]

Even when the hip replacement itself is approved, billing denials and scheduling chaos can happen if the admission status is not supported. Medicare guidance emphasizes documentation supporting inpatient admission decisions, including the “two-midnight” expectation and case-by-case exceptions when a stay is expected to be shorter but inpatient care is still reasonable based on complex medical factors. ^[2]

Patient move: Ask your surgeon’s office: “Is my surgery planned as inpatient or outpatient, and is that status authorized with my insurer?”

Objection 1: “Conservative therapy not tried long enough” or “not documented”

Fix:

• Gather physical therapy notes, medication history, and documented activity modification.
• If conservative care was not appropriate (for example, collapse of the femoral head), make sure the clinician explicitly documents why. ^[3]

If your plan has specific timing requirements (for example, 12 weeks of physical therapy or home exercise), highlight those dates clearly. ^[4]

Objection 2: “Imaging does not support severity” or “imaging report missing detail”

Fix:

• Submit the full radiology report with impression and detailed findings.
• If requested, submit the specific images that show the abnormality (some insurers state they may require this). ^[4]

Medicare contractor guidance also lists the imaging findings that should be documented when surgery is indicated for advanced joint disease. ^[2]

Objection 3: “Symptoms and functional limitation not severe enough”

Fix:

• Provide a short addendum note from the surgeon or primary care clinician describing how pain interferes with activities of daily living, weight-bearing, walking distance, sleep, and work demands. ^[2]

Objection 4: “Physical exam does not support request”

Fix:

Ensure the clinical note includes range of motion limitation, gait issues, and pain with passive motion, which appear in medical necessity criteria examples. ^[1]

Objection 5: “Contraindications or safety concerns”

Fix:

Provide documentation that active infection or wounds are not present. If there are risk factors (for example, very high body weight or multiple medical conditions), ensure the chart reflects a risk–benefit discussion and optimization steps. ^[1]

Hip fracture:

Hip replacement for fracture can be treated differently than elective arthritis cases. Some criteria frameworks include fracture imaging and note that conservative management or fixation may not be reasonable in that scenario. ^[3]

Avascular necrosis:

Documentation often needs imaging evidence of avascular necrosis and collapse stage or severe, persistent pain despite treatment. ^[1]

Inflammatory arthritis:

Records should show inflammatory arthritis affecting the hip joint (for example, joint space narrowing) plus functional limitations and failed nonsurgical management where applicable. ^[3]

Medicare does not have a single national coverage determination for hip replacement in many cases, so local Medicare contractors provide documentation guidance and local coverage determinations.

One Medicare coverage article states the medical record must fully support medical necessity and warns that missing information in the hospital record can risk denial of Part A inpatient services and trigger review of Part B provider claims. ^[2]

It also describes what should be documented when surgery is for advanced joint disease, including:

• arthritis supported by imaging and documented imaging findings (such as joint space narrowing, osteophytes, sclerosis, bone-on-bone, avascular necrosis),
• and pain or functional disability described in context (for example, interference with activities of daily living or pain with weight bearing). ^[2]

If you are a Medicare patient, it is especially important that your surgeon’s note, imaging reports, and functional limitation narrative are all in the record before admission.

When you call or message the scheduling team, you can say:

“I want to make sure my hip replacement pre-approval is approval-ready. Can you confirm the request includes my imaging report with detailed findings and impression, my nonsurgical treatment history with dates (medications, physical therapy, activity modification), my functional limitations in daily activities, and my physical exam findings? Also, can you share the authorization reference number and approved date range once it’s submitted?”

This phrasing is helpful because it mirrors what many policies and documentation guidance explicitly ask reviewers to see. ^[1]

“Does my age affect approval?”

Most clinical guidance emphasizes that candidacy is driven more by pain and disability than by age alone. ^[6]

“Do I need injections before hip replacement?”

Not always. Some policies state injections may be appropriate but are not a requirement for conservative therapy documentation. ^[1]

“What is the single biggest reason for delay?”

In real-world utilization review, it is usually missing or unclear documentation, especially around conservative therapy dates, functional limitations, and imaging details. Insurers explicitly warn that failure to submit requested documentation may delay review or lead to denial. ^[5]

A successful hip replacement pre-approval is not about having the “perfect” diagnosis. It’s about having a complete, consistent, well-dated record that matches insurer criteria:

• diagnosis appropriate for hip replacement, ^[1]
• imaging proof of advanced joint damage, ^[1]
• significant pain and daily function limitation, ^[2]
• and documented nonsurgical treatment efforts (or documented exceptions). ^[1]

If you follow the checklist above and keep the documentation organized, you dramatically reduce the chance of delays or last-minute cancellations, so you can focus on the surgery and recovery, not insurance paperwork.