TL;DR: Aetna, a CVS Health company, modified CPB 0661 covering joint resurfacing, effective December 20, 2025. If your team bills HCPCS S2118, CPT 27130, or CPT 27125 for hip resurfacing procedures, the updated criteria and contraindication list directly affect your prior authorization and claim denial risk.
The Aetna joint resurfacing coverage policy under CPB 0661 Aetna system sets strict medical necessity rules for metal-on-metal hip resurfacing—and the contraindication list alone is long enough to sink claims that might look clean at first glance. This update is worth a close read before your next authorization submission.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Joint Resurfacing — CPB 0661 |
| Policy Code | CPB 0661 |
| Change Type | Modified |
| Effective Date | December 20, 2025 |
| Impact Level | High |
| Specialties Affected | Orthopedic Surgery, Sports Medicine, Hand Surgery, Shoulder Surgery |
| Key Action | Audit all pending hip and shoulder resurfacing prior auth requests against updated criteria before submitting claims after December 20, 2025 |
Aetna Joint Resurfacing Coverage Criteria and Medical Necessity Requirements 2025
The Aetna joint resurfacing coverage policy is narrow by design. Metal-on-metal hip resurfacing is medically necessary only when performed with an FDA-approved device — specifically the Birmingham Hip Resurfacing (BHR) System or the Cormet 2000. No other devices qualify under this policy.
The target patient is physically active, under 65, and would otherwise need a conventional total hip replacement. That framing matters for your documentation. The clinical rationale must show that a standard prosthesis would likely fail before end of life — not just that the patient has severe joint disease.
Medical necessity requires ALL of the following:
| # | Covered Indication |
|---|---|
| 1 | Pain and functional disability interfering with activities of daily living (ADLs), caused by osteoarthritis, avascular necrosis, or post-traumatic arthritis |
| 2 | Limited range of motion (ROM), antalgic gait, and hip pain on passive ROM during physical examination |
| 3 | Radiographic or MRI evidence of severe osteoarthritis — documented by two or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, bone-on-bone articulation, or joint space narrowing — primarily affecting the femoral head; OR osteonecrosis of the femoral head with less than 50% femoral head involvement |
| 4 | Normal proximal femoral bone geometry and bone quality |
| 5 | Member would require conventional primary total hip replacement but is expected to outlive a traditional prosthesis |
| 6 | At least 12 weeks of documented conservative therapy — including all of the following unless contraindicated: anti-inflammatory medications or analgesics, flexibility and muscle strengthening exercises, activity modification, supervised physical therapy with documented ADL decline despite completing a plan of care, weight reduction where appropriate, assistive device use, and therapeutic hip injections |
Every one of those boxes needs to be checked in the medical record. Aetna will look for all of them on prior authorization review. If your documentation skips even one element — say, therapeutic injections — you're exposing yourself to a claim denial.
For members with significant comorbidities, the record must also directly address the risk/benefit of hip resurfacing. Don't leave that to implication. The medical director's note should state it explicitly.
Joint resurfacing billing under this policy — specifically HCPCS S2118 and CPT 27130 — requires ironclad documentation. Reimbursement depends on it.
Aetna Joint Resurfacing Exclusions and Non-Covered Indications
Aetna considers metal-on-metal hip resurfacing experimental, investigational, or unproven for any indication not listed in the medical necessity criteria above. That's a hard line. If the patient presentation doesn't fit the covered profile, don't bill it as covered.
The contraindication list is where claims die most often. Aetna considers hip resurfacing not medically necessary for members with any of the following:
| # | Excluded Procedure |
|---|---|
| 1 | Active joint infection or active systemic bacteremia not fully eradicated |
| 2 | Active skin infection or open wound within the planned surgical site (recurrent cutaneous staph infections are an exception) |
| 3 | Known allergy to cobalt, chromium, or alumina — the metals used in resurfacing |
| 4 | Inactive or older individuals unlikely to outlive a traditional total hip replacement (THR) |
| 5 | Morbid obesity — BMI greater than 40 (ICD-10 E66.01) |
| 6 | Inadequate bone stock to support the device |
| 7 | Avascular necrosis with more than 50% femoral head involvement |
| 8 | Severe anatomic deformity of the femoral head |
| 9 | Skeletal immaturity |
| 10 | Moderate-to-severe renal insufficiency — GFR less than 60 mL/min/1.73 m² |
| 11 | Multiple femoral neck cysts |
The renal insufficiency criterion deserves special attention. A GFR under 60 is not an uncommon finding in the patient population that presents for joint replacement. Screen for it. If the preoperative workup shows impaired renal function, prior authorization will not go through — and a claim submission won't survive appeal without addressing it head-on.
The morbid obesity cutoff at BMI > 40 is equally firm. ICD-10 code E66.01 in the diagnosis string is a signal to Aetna's system. If that code appears alongside S2118 or 27130, expect scrutiny.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Metal-on-metal hip resurfacing with FDA-approved device (BHR, Cormet 2000) in physically active adults under 65 with advanced joint disease | Covered | S2118, CPT 27130 | All medical necessity criteria must be met; prior auth required |
| Hip resurfacing for patients with BMI > 40 | Not Covered | S2118 | ICD-10 E66.01 is a red flag in claims review |
| Hip resurfacing with GFR < 60 mL/min/1.73 m² | Not Covered | S2118 | Renal insufficiency is an absolute contraindication |
| Hip resurfacing with > 50% femoral head involvement from osteonecrosis | Not Covered | S2118 | Only early-stage AVN with < 50% involvement qualifies |
| Hip resurfacing with active joint infection or systemic bacteremia | Not Covered | S2118 | Infection must be fully eradicated before consideration |
| Hip resurfacing in skeletally immature patients | Not Covered | S2118 | Age and skeletal maturity both required |
| Hip resurfacing with metal allergy (cobalt, chromium, alumina) | Not Covered | S2118 | Screen preoperatively; document allergy status |
| Hemiarthroplasty, hip | Covered (criteria met) | CPT 27125 | Per AAOS guidance; selection criteria apply |
| Total hip arthroplasty | Covered (criteria met) | CPT 27130 | Standard coverage for qualifying indications |
| Shoulder resurfacing (hemiarthroplasty) | Related — no specific code | CPT 23470 | No dedicated resurfacing code; billed under hemiarthroplasty |
| Total shoulder resurfacing | Related — no specific code | CPT 23472 | No dedicated resurfacing code; billed under total shoulder |
| Proximal row carpectomy with capitate resurfacing | Related | CPT 25215 | Wrist-specific; traumatic arthropathy ICD-10 M12.541–M12.549 |
| Metal-on-metal hip resurfacing for all other indications | Experimental/Investigational | S2118 | Not covered outside defined criteria |
Aetna Joint Resurfacing Billing Guidelines and Action Items 2025
The effective date of December 20, 2025 means these criteria are already active. If your team has pending authorizations or scheduled procedures, act now.
| # | Action Item |
|---|---|
| 1 | Audit all in-flight prior authorization requests for hip resurfacing. Pull every open request billed under S2118 or CPT 27130. Compare the documented criteria against the updated CPB 0661 checklist — all 12 weeks of conservative therapy, all seven conservative treatment modalities, imaging findings, age, and activity level. Close any documentation gaps before the case goes to surgery. |
| 2 | Add a renal function screen to your pre-auth intake workflow. GFR below 60 mL/min/1.73 m² is an automatic disqualifier. Build a checkbox into your authorization form that confirms the patient's GFR. This one step prevents a predictable denial. |
| 3 | Flag E66.01 in your charge capture system. Morbid obesity with BMI > 40 (ICD-10 E66.01) is a hard contraindication. If your charge capture or EHR pulls this code as a comorbidity, your team needs a manual review step before submitting the claim. |
| 4 | Confirm the device is FDA-approved before billing S2118. Only the Birmingham Hip Resurfacing System and the Cormet 2000 qualify under this coverage policy. If the surgeon uses a different device — even a newer one — Aetna will deny it as experimental. Get the device confirmation in writing from the OR before claim submission. |
| 5 | Document AVN femoral head involvement percentage explicitly. The policy cuts at 50% femoral head involvement. Radiology reports often describe osteonecrosis without quantifying involvement. Your pre-auth documentation needs the radiologist or surgeon to state clearly whether involvement is above or below 50%. "Significant osteonecrosis" won't clear authorization. |
| 6 | Review shoulder resurfacing billing separately. CPT 23470 (glenohumeral hemiarthroplasty) and CPT 23472 (total shoulder) are listed as related codes — but Aetna's policy notes there is no specific code for shoulder resurfacing. This creates real billing ambiguity. If your team performs shoulder resurfacing and bills under these CPT codes, loop in your compliance officer before the effective date to confirm the documentation strategy. |
| 7 | Pull the ICD-10 code list for supported diagnoses. With 267 ICD-10-CM codes in scope — covering sepsis, immune disorders, pyogenic arthritis, traumatic arthropathy, and more — your diagnosis coding has to be precise. A mismatched ICD-10 code relative to the clinical picture is a fast path to claim denial. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Joint Resurfacing Under CPB 0661
Covered CPT and HCPCS Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| S2118 | HCPCS | Metal-on-metal total hip resurfacing, including acetabular and femoral components |
| 27125 | CPT | Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty) |
| 27130 | CPT | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) |
Other CPT Codes Related to CPB 0661
These codes appear in the policy but are not primary resurfacing codes. They represent related procedures that may appear in the same episode of care or authorization.
| Code | Type | Description |
|---|---|---|
| 25215 | CPT | Carpectomy; all bones of proximal row [proximal row carpectomy with capitate resurfacing] |
| 27033 | CPT | Arthrotomy hip, including exploration or removal of loose or foreign body |
| 27122 | CPT | Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure) |
| 27132 | CPT | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft |
| 27360 | CPT | Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula |
| 23470 | CPT | Arthroplasty, glenohumeral joint; hemiarthroplasty [shoulder resurfacing — no specific code] |
| 23472 | CPT | Arthroplasty, glenohumeral joint; total shoulder — glenoid and proximal humeral replacement [shoulder resurfacing — no specific code] |
Key ICD-10-CM Diagnosis Codes
This policy references 267 ICD-10-CM codes. The table below covers the primary categories directly relevant to hip and joint resurfacing billing decisions.
| Code | Description |
|---|---|
| E66.01 | Morbid (severe) obesity due to excess calories — contraindication (BMI > 40) |
| I73.9 | Peripheral vascular disease, unspecified |
| I87.2 | Other disorders of veins |
| I87.8 | Other disorders of veins |
| I87.9 | Other disorders of veins |
| I99.8 | Other disorder of circulatory system |
| M00.051–M00.059 | Pyogenic arthritis, hip |
| M00.151–M00.159 | Pyogenic arthritis, hip |
| M00.251–M00.259 | Pyogenic arthritis, hip |
| M00.851–M00.859 | Pyogenic arthritis, hip |
| M00.9 | Pyogenic arthritis, unspecified |
| M01.X51–M01.X59 | Direct infection of hip in infectious and parasitic diseases classified elsewhere |
| M07.611–M07.619 | Enteropathic arthropathies, shoulder |
| M12.511–M12.519 | Traumatic arthropathy, shoulder |
| M12.541–M12.549 | Traumatic arthropathy, wrist [scapholunate advanced collapse] |
| M12.811–M12.819 | Other specific arthropathies, not elsewhere classified, shoulder |
| M12.9 | Arthropathy, unspecified, shoulder |
| M13.0 | Polyarthritis, unspecified, shoulder |
| M13.111–M13.119 | Monoarthritis, not elsewhere classified, shoulder |
| A41.1–A41.9 | Other sepsis (multiple subcategories) |
| A46 | Erysipelas |
| D80.0–D84.9 | Certain disorders involving the immune mechanism (multiple subcategories) |
| D89.810–D89.9 | Certain disorders involving the immune mechanism |
| G70.00–G73.3 | Myasthenia gravis and other myoneural disorders (neuromuscular disease) |
The full ICD-10 list in CPB 0661 spans 267 codes. Pull the complete list directly from the policy source at app.payerpolicy.org/p/aetna/0661 to confirm your specific diagnosis codes are supported before submission.
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