If Orthopedic Surgery Is Your First Course of Treatment, Request a Predetermination of Medical Necessity to Avoid Unexpected Costs

The Health Plan covers medically necessary orthopedic surgeries (i.e., shoulder, knee, back, etc.) for covered participants and their dependents. One of the Health Plan’s criteria for determining medical necessity includes whether the procedure or service is consistent with generally accepted medical guidelines and practices, which may require that certain treatment options be administered prior to or instead of others. When standard medical practice is not followed, treatment may sometimes be deemed not medically necessary and, therefore, will not be covered under the Health Plan.

With regard to orthopedic surgeries, doctors sometimes recommend immediate surgery without attempting non-surgical treatments prior to surgical intervention. While your doctor may believe that immediate surgery is necessary, it may not be medically necessary under the terms of the Health Plan if there is no documentation of attempted non-surgical treatments. If surgery is done and is later determined to be not medically necessary, you may be held responsible for the full cost of the procedure, leaving you with significant unanticipated expenses.


Orthopedic surgeries might be recommended by doctors as a first course of treatment. Surgery as a first response, however, is generally not standard medical practice in treating orthopedic conditions and may not be considered medically necessary by the Health Plan. If your doctor is advising that your condition does not require standard medical care prior to surgery, the rationale for this decision needs to be clearly documented in your medical records. According to standard medical practice, before advancing to orthopedic surgery, you should have first tried the following modalities/studies:

  • Nonsteroidal anti-inflammatory drug
  • Physical therapy
  • Home exercise program
  • Cortisone injections
  • Medications
  • Diagnostic imaging confirming diagnosis

Although a surgery might seem like a single procedure, in reality, it might include several related procedures, each of which must be evaluated for coverage by the Health Plan. When in doubt, review each of the planned procedures with your doctor so you have a full understanding of your surgery and its costs. If you are uncertain as to whether or not your orthopedic surgery is medically necessary, you should request a voluntary predetermination from the Health Plan before receiving the service. A predetermination will help you evaluate ahead of time whether the treatment is considered medically necessary and whether it will be covered. For more information regarding how to submit a predetermination, go to www.dgaplans.org/predeterminations.