“BCBST
UM Guidelines
Orthopedic

Listed by Conditions


Achilles Tendon Repair

Acromioplasty and Rotator Cuff Repair

Ankle Dislocation, Closed or Open Reduction

Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF)

Arthrography, MR

Bone Excision

Cervical Fusion, Anterior

Elbow Fracture, Open Treatment

Elbow Arthroplasty

Femur Fracture, Removal of Internal Fixation Device

Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF)

Hip Arthroplasty

Hip Resurfacing

Humerus Fracture, Closed or Open Reduction

Knee Arthroplasty, Total

Knee Arthrotomy

Knee Dislocation, Closed or Open Reduction

Knee: Fracture of Tibial Plateau, Closed or Open Reduction

Knee: Patella Reconstruction or Realignment for Recurrent Dislocation

Lumbar Diskectomy, Foraminotomy, or Laminotomy

Lumbar Laminectomy

Slipped Upper Femoral Epiphysis, Closed Reduction

Tibia/Fibula Shaft Fracture, Closed or Open Reduction

Tibial Osteotomy, Adult

Vertebroplasty and Kyphoplasty

Wrist Arthroplasty