Hip Replacement Insurance Denial Appeal Guide

Common Denial Reasons

1. Conservative treatment duration not met
2. Imaging doesn't meet severity criteria
3. Missing functional limitation documentation
4. Prior authorization lapse
5. BMI restrictions

Required Documentation

• Standing pelvic AP X-ray with both hips
• Lateral hip X-ray
• Harris Hip Score or HOOS documentation
• Failed conservative treatment log (PT, injections, medication trials)
• Orthopedic surgeon assessment and recommendation
• Impact on work, mobility, and daily activities

Appeal Strategy

1. Orthopedic surgeon letter detailing clinical findings
2. Kellgren-Lawrence Grade 3-4 documentation
3. Failed injection therapy (with dates and limited response duration)
4. Functional limitation specifics (walking distance, need for assistive devices)
5. Risk of delay (joint deterioration, compensatory injury to other joints)
6. Cite AAOS and ACR guidelines