Prior authorization for knee and hip replacement
Joint replacement is a planned procedure, so reviewers expect the file to show a clear path: advanced disease on imaging, a sustained trial of non-surgical treatment, significant pain and loss of function, and a patient whose surgical risks have been addressed. Requests are most often held up by the second and fourth parts.
What reviewers typically require
- Weight-bearing radiographs with the findings described: joint space narrowing, osteophytes, subchondral sclerosis or cysts, deformity, and a radiographic severity grade where the report gives one.
- Non-surgical treatment over a sustained period, listed item by item: analgesics and anti-inflammatories, physiotherapy or a structured exercise programme, weight loss advice where relevant, intra-articular injections, walking aids, activity modification.
- Pain that limits daily activity or disturbs sleep, with a pain score.
- A validated function score for the knee or hip, and daily examples: walking distance, stairs, getting in and out of a car.
- Examination: range of motion, deformity, effusion, gait.
- Risk optimisation: body mass index, HbA1c in diabetes, smoking status, skin condition, any active infection, and dental review where your pathway requires it.
Getting the conservative care section right
This is where most delays happen. Reviewers do not accept 'failed conservative management' as a phrase. They want each measure named, with when it started, how long it lasted and what happened. Physiotherapy should have a number of sessions or weeks. Injections should have dates and the duration of any relief. If a measure was not tried, the reason should be stated, for example that anti-inflammatories are contraindicated because of kidney disease.
A table in the letter can help when the history is long, but for most patients three or four short lines are enough.
Example
Request: Right total knee arthroplasty (27447). Diagnosis: Unilateral primary osteoarthritis, right knee (M17.11). [Patient initials], 66. Right knee pain for 4 years, now 8/10 on walking and waking the patient most nights. Walking limited to about 200 metres with a stick; unable to manage stairs without a rail. Radiographs (standing, this year): severe medial joint space loss with bone-on-bone contact, large osteophytes and 8 degrees of varus. Non-surgical treatment: - Paracetamol and topical NSAID, over 2 years; oral NSAIDs stopped for dyspepsia. - Physiotherapy, 10 sessions over 3 months last year, with home exercise since. - Two corticosteroid injections; relief lasted 6 weeks and then 2 weeks. - Weight reduced from BMI 33 to 30 with dietitian support. Validated knee function score in the severe range today. HbA1c 6.9%. Non-smoker. No skin lesions over the knee.
Common problems and fixes
| Problem | Fix in the documentation |
|---|---|
| Imaging older than the criteria accept, or not weight-bearing | Order current standing views and quote the report |
| Laterality mismatch between diagnosis and procedure | Right knee procedure with M17.11, left with M17.12; bilateral osteoarthritis is M17.0 |
| Injection history without dates | Each injection's date and how long relief lasted |
| Risk factor not addressed | The current value and the plan, such as an HbA1c target before a surgery date |
Hip replacement follows the same logic: total hip arthroplasty is 27130, and unilateral primary osteoarthritis of the right hip is M16.11. ClearPass drafts the request from your orthopaedic or primary care note, adds ICD-10 and procedure codes, and asks about missing items such as injection dates. Pick Concise, Standard or Detailed, edit, and file it yourself. Before surgery, the patient may also need a physiotherapy request for prehabilitation or recovery.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
How long must conservative treatment last?
Criteria vary, and several months of documented treatment is a common expectation. Write the actual dates; do not round up.
What if the patient has already had injections elsewhere?
Include them with approximate dates and the effect, and say where the information came from. Reviewers accept a documented history from the patient or an earlier clinician.
Can it write the request for a revision operation?
It drafts from what the note documents. Revision cases hinge on the reason for revision, such as loosening, infection or instability, with imaging and test results, so make sure those are in the note.
What does ClearPass cost?
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