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Yes - typically coveredPrior auth: Always required

Does Aetna cover total hip replacement?

Total hip replacement is a covered medical procedure under all major health insurance plans when the clinical indication is supported by imaging and documented failed conservative care. Commercial insurers and Medicare Advantage plans require prior authorization. Original Medicare covers hip replacement under Part A (inpatient) or Part B (outpatient ASC), paying 80% after deductible.

Quick summary

Coverage

Yes - typically covered

Prior authorization

Always required

Typical patient cost

Commercial insurance patient cost: $1,000-$4,500 depending on deductible and plan design. Medicare beneficiaries with Medigap pay little or nothing beyond the deductible. Uninsured patients face hospital-billed charges that often exceed $35,000-$50,000.

Prior authorization for Aetna

Aetna covers standard orthopedic care: evaluations, imaging, conservative treatment, and surgery. They use a Centers of Excellence program for complex procedures like spinal fusion and joint replacement, where members may pay less when using a designated facility. PPO members can self-refer to specialists. HMO members go through their primary care doctor first. Prior authorization is required for most surgical procedures.

Always verify your specific Aetna plan before scheduling. Plans within the same insurer (Aetna) can have different prior authorization rules, network requirements, and cost-sharing. Call the number on the back of your insurance card or log into your plan portal to confirm coverage for your specific plan.

How to confirm your coverage before scheduling

  1. 1Call Aetna member services (number on back of your insurance card) and ask specifically if total hip replacement is covered under your plan.
  2. 2Ask your orthopedic surgeon's office to verify benefits on your behalf - they do this routinely and can identify in-network requirements.
  3. 3Request the prior authorization criteria in writing if prior auth is required. Ask what documentation is needed from your surgeon.
  4. 4Confirm your deductible remaining for the year - your out-of-pocket cost depends on where you are in the deductible cycle.
  5. 5Get a pre-service cost estimate from the facility if you want a specific dollar figure before scheduling.

What to do if Aetna denies coverage

Insurance denials for orthopedic procedures are common and frequently overturned on appeal. Follow these steps:

  1. 1Request the denial reason in writing
  2. 2Ask for a peer-to-peer review between your surgeon and the insurer's medical reviewer
  3. 3Document conservative treatment attempts with dates, provider notes, and outcomes
  4. 4File a formal internal appeal with clinical documentation attached
  5. 5Escalate to external review if denied again
  6. 6Contact your employer's HR benefits team if using an employer-sponsored plan - they can often expedite appeals

Common questions

Will insurance cover outpatient hip replacement?
Yes, increasingly. CMS removed total hip replacement from the Medicare Inpatient-Only list in 2020. Commercial insurers have followed. Outpatient (same-day discharge) hip replacement at ambulatory surgery centers is now widely covered when the surgeon and facility are certified for it.
Does insurance cover hip resurfacing?
Yes, in most cases. Hip resurfacing is covered under the same medical necessity criteria as total hip replacement. Some plans classify it identically; others require separate prior authorization documentation. Confirm your plan's specific code coverage with your surgeon's billing office.
How long does insurance prior auth for hip replacement take?
Commercial insurer reviews take 3-10 business days for standard requests. Urgent requests are reviewed within 72 hours. Medicare Advantage plans vary by carrier but generally follow similar timelines. Original Medicare has no prior auth requirement.

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