MEDICAL POLICY – 7.01.550

Knee Arthroplasty in Adults

Effective Date: April 1, 2020

Last Revised: June 1, 2020

Replaces: N/A

RELATED MEDICAL POLICIES:

7.01.15 Meniscal Allograft and Other Meniscal Implants

7.01.144 Patient-Specific Cutting Guides for Joint Arthroplasty

7.01.549 Knee Arthroscopy in Adults

Select a hyperlink below to be directed to that section.

POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING

RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Knee arthroplasty is the medical term for a total knee replacement. A surgeon removes the

damaged part of the joint. The surfaces are shaped to hold a replacement joint that is either

metal or plastic. The artificial joint is attached to the thigh bone, shin bone, and knee cap. For

the right patient, a knee replacement reduces pain and improves quality of life. People who may

qualify for this surgery are those who have severe pain from “wear-and-tear” arthritis

(osteoarthritis) of the knee, who are not able to perform their normal daily activities, and who

tried nonsurgical treatments. Replacement joints have a limited life. Factors such as a person’s

age, severity of knee disease, obesity, and the type of replacement affect how long an artificial

joint will last. Knee arthroplasty must be pre-approved by the health plan. This policy outlines

the information needed for health plan review.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The

rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for

providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can

be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a

service may be covered.

Policy Coverage Criteria

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Note: This policy only applies to those aged 18 and over. This policy does not apply to

patellofemoral knee arthroplasty

Indication Medical Necessity Osteoarthritis or

degenerative joint disease

Total knee and unicompartmental arthroplasty may be

considered medically necessary for degenerative joint disease

when ALL of the following are met:

• Treatment is needed because of one or more of the following:

o Disabling pain for at least 3 months duration

o Functional disability which interferes with the ability to carry

out activities of daily living

AND

• Radiographic or imaging evidence of severe osteoarthritis in

the 12 months prior to surgery evidenced by either:

o Moderate multiple or large osteophytes, definite or marked

narrowing of joint space, some or severe sclerosis and

possible or definite deformity of bone contour (Kellgren-

Lawrence grade of 3 or 4)

OR

o Exposed subchondral bone (full thickness cartilage loss with

underlying bone reactive changes)

AND

• Documentation of three months of failed non-operative,

conservative management for Kellgren-Lawrence grade 3

findings as demonstrated by a trial of one or more of the

following medications:

o Non-steroidal anti-inflammatory drugs (oral or topical)

o Acetaminophen

o Intra-articular injection of corticosteroids as appropriate

AND

• A trial of one or more of the following physical measures:

o Physical therapy

o Flexibility and muscle strengthening exercises

o Reasonable restriction of activities

OR

• For Kellgren-Lawrence grade 4 findings, a trial of one or more

of the following medications:

o Non-steroidal anti-inflammatory drugs (oral or topical)

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Indication Medical Necessity o Acetaminophen

o Intra-articular injection of corticosteroids as appropriate

Replacement/revision of

previous arthroplasty

Knee arthroplasty may be considered medically necessary for a

replacement/revision of a previous arthroplasty as indicated

by one or more of the following:

• Disabling pain

• Functional disability

• Progressive and substantial bone loss

• Fracture or dislocation of patella

• Aseptic component instability or loosening

• Infection

• Periprosthetic fracture

Other Conditions Knee arthroplasty may be considered medically necessary for

the following diagnoses:

• Distal femur fracture repair in a patient with osteoporosis

• Failure of a previous proximal tibial or distal femoral osteotomy

• Hemophilic arthroplasty

• Limb salvage for malignancy

• Posttraumatic knee joint destruction

Documentation Requirements The patient’s medical records submitted for review for all conditions should document that

medical necessity criteria are met. The record should include the following:

• For osteoarthritis or degenerative joint disease with ALL of the following:

o Needs treatment because of disabling pain and/or limited knee function interfering with

activities of daily living (ADLs)

AND

o Imaging evidence of severe osteoarthritis by either: large osteophytes (bone spurs), severe

narrowing of joint space, severe sclerosis (thickening, hardening, increase in density), and

definite deformity of bone contours. Radiologic or imaging must be done in the 12 months

prior to planned surgery

AND

o History of unsuccessful conservative/medical management such as anti-inflammatory

medication, analgesics, physical therapy, flexibility and muscle strengthening exercises, or

reasonable restriction of activities

• For replacement/revision of previous arthroplasty with evidence of one of the following:

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Documentation Requirements o Disabling pain

o Limited knee function

o Progressive and substantial bone loss

o Patella (kneecap) fracture or dislocation

o Aseptic component instability (a non-infectious loosening of the bond between the bone

and the implant)

o Infection

o Periprosthetic fracture (fracture around the knee implant)

• For other significant conditions, detailed clinical documentation supporting the diagnoses of

one of the following:

o Repair of distal femur fracture (fracture of the femur just above the knee joint) in a patient

with osteoporosis

o Failure of a previous proximal tibial or distal femoral osteotomy (cutting or removal of

bone related to a break in the shinbone just below the knee or the femur just above the

knee)

o Hemophilic arthroplasty (knee replacement for a person with hemophilia)

o Limb salvage for malignancy

o Posttraumatic knee joint destruction

Coding

Code Description

CPT 27446 Arthroplasty, knee condyle and plateau; medial OR lateral compartment

(unicompartmental or partial knee replacement)

27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or

without patella resurfacing (total knee arthroplasty)

27486 Revision of total knee arthroplasty, with or without allograft; 1 component

27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial

component

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS

codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

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Related Information

KOOS Knee Survey

It is widely agreed that good outcome measures are needed to be able to tell the difference

between treatments that are effective from those that are not. In order to do this, there must be

some standardized, patient-centered measures that can be administered at a low cost. A

questionnaire (the Knee Injury and Osteoarthritis Outcome Scores, or KOOS) was developed to

evaluate short- and long-term patient-relevant outcomes after knee injury. This questionnaire

was based on the WOMAC (Western Ontario and McMaster Universities) Osteoarthritis Index, a

literature review, an expert panel, and a pilot study. The KOOS is a tool that can be used in the

provider’s office. It is self-administered and looks at five outcomes: pain, symptoms, activities of

daily living, sport and recreation function, and knee-related quality of life.7 It has been shown to

be a useful tool in assessing a patient’s pain and functional disability.

Kellgren-Lawrence Grading Scale

• Grade 1: Doubtful narrowing of joint space and possible osteophytic lipping

• Grade 2: Definite osteophytes, definite narrowing of joint space

• Grade 3: Moderate multiple osteophytes, definite narrowing of joints space, some sclerosis

and possible deformity of bone contour

• Grade 4: Large osteophytes, marked narrowing of joint space, severe sclerosis and definite

deformity of bone contour

Modified Outerbridge Classification

• Grade 1: Signal intensity alterations with an intact surface of the articular cartilage compared

with the surrounding normal cartilage

• Grade 2: Partial thickness defect of the cartilage

• Grade 3: Fissuring of the cartilage to the level of the subchondral bone

• Grade 4: Exposed subcondral bone

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Modern total knee arthroplasty consists of resection of the diseased articular surfaces of the

knee, followed by resurfacing with metal and polyethylene prosthetic components. For the

properly selected patient, the procedure results in significant pain relief, as well as improved

function and quality of life. Despite the potential benefits of total knee arthroplasty, it is an

elective procedure and should only be considered after extensive discussion of the risks,

benefits, and alternatives.1

The main indication for total knee arthroplasty is for the relief of pain associated with arthritis of

the knee in patients who have failed nonoperative treatments. Correction of deformity and

restoration of function should be considered secondary outcomes of the surgery and should not

be considered the primary indication. The prosthetic joint has a finite lifetime, and the durability

of the prosthesis depends on many factors such as patient age, underlying disease, the presence

of obesity, as well as the type of prosthesis and surgical factors.2

Patients with osteoarthritis limited to just one part of the knee may be candidates for

unicompartmental knee replacement (also called a “partial” knee replacement).

Unicompartmental knee replacements are an option for a small percentage of patients with

osteoarthritis of the knee. In a this type of surgery, only the damaged knee compartment is

replaced with metal and plastic.3

Evidence Review

Knee arthroplasty may be done to treat both posttraumatic arthritis and osteoarthritis.

Although excellent long-term outcomes can be seen with modern methods of ligament

reconstruction and open reduction and internal fixation for knee injuries, posttraumatic knee

arthritis often develops. Options to treat symptomatic posttraumatic knee arthritis include

osteotomy, arthrodesis, and arthroplasty. There may be surgical challenges including the

presence of extensive (often broken) hardware, scarring, stiffness, bony defects, compromised

soft tissues, and malalignment. When deciding on a treatment plan, the patient’s age and level

of activity must be taken into account, as well as the anatomic location and extent of damage to

the articular surface. For younger patients, osteotomy, allograft transplantation, or arthrodesis of

the knee is often considered, whereas older, low-demand patients are typically treated with

arthroplasty. Attention to specific technical details and careful surgical technique are required in

order to achieve a successful result. Functional improvement is usually seen following

arthroplasty and, sometimes, after arthrodesis. However, complications are common.3

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In people with advanced osteoarthritis of the knee, knee replacement surgery is often done as a

way to relieve pain and improve function. Carr et al4 surveyed the epidemiology and risk factors

for knee replacement surgery.

In 2010, Bozic et al5 looked at the relationship between the number of procedures that a

surgeon and hospital do and the clinical outcomes of those procedures. They found that the

patients of surgeons who performed more knee replacements had a lower risk of complications,

lower readmission and reoperation rates, shorter length of stay, and a higher chance that they

would be discharged to home. Hospitals that did more knee replacement surgeries had lower

mortality, lower risk of readmission, and a higher likelihood of the patient being discharged to

home. Bozic et al also found that when the surgeon and hospital closely follow evidence-based

processes of care, there were better clinical outcomes and shorter lengths of stay, regardless of

how many procedures the surgeon and hospital had performed.

In 2009, the Osteoarthritis Research Society International (OARSI) updated their global,

evidence-based, consensus recommendatons that had been done in 2006. They found that

there were 64 systematic reviews, 266 randomized controlled trials (RCTs) and 21 new economic

evaluations (EEs). New data on efficacy had been published for more than half (26/39, or 67%) of

the 51 new treatment modalities. They found that there had been changes in the calculated risk-

benefit ratio for some osteoarthritis treatments.6

References

1. Martin G, Thornhill T, Katz J. Total Knee Arthroplasty. Available on-line. UpToDate, Furst, D (Ed), UpToDate®, Waltham, MA,

2013.

2. American Academy of Orthopaedic Surgeons. Unicompartmental knee replacement, patient information. 2016, Available online

at: http://orthoinfo.aaos.org/topic.cfm?topic=A00585 Accessed November 2019.

3. Bedi A, Haidukewych GJ. Management of the posttraumatic arthritic knee. Journal of the American Academy of Orthopedic

Surgeons 2009;17(2):88-101.

4. Carr AJ, et al. Knee replacement. Lancet 2012;379(9823):1331-40.

5. Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of

care on quality and efficiency in total joint replacement surgery. Journal of Bone and Joint Surgery. American Volume

2010;92(16):2643-52.

6. Zhang W, Nuki G, Moskowtiz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III:

Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis

Cartilage 2010; 18:476. Available online at:

http://oarsi.org/sites/default/files/library/2013/pdf/part_iii_changes_in_evidence2010.pdf Accessed November 2019.

http://orthoinfo.aaos.org/topic.cfm?topic=A00585http://oarsi.org/sites/default/files/library/2013/pdf/part_iii_changes_in_evidence2010.pdf

Page | 8 of 10 ∞

7. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)-development

of a self-administered outcome measure. J Orthop Sports Phys Ther 1998; Aug 28(2): 88-96 Available at: http://www.koos.nu

Accessed November 2019.

8. Reviewed by board certified orthopedic specialists, October 2013.

9. American Academy of Orthopaedic Surgeons. Surgical Management of Osteoarthritis of the Knee. 2015. Available online at:

http://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/SMOAK%20CPG_4.22.2

016.pdf Accessed November 2019.

10. Gademan MG, Hofstede SN, et al. Indication criteria for total hip or knee arthroplasty in osteoarthritis: a state-of-the-science

overview. BMC Musculoskelet Disord 2016; Nov 9; 17 (1): 463. PMID 27829422.

11. American Academy of Orthopaedic Surgeons. Total Knee Replacement, 2015. Available online at:

https://orthoinfo.aaos.org/en/treatment/total-knee-replacement Accessed November 2019.

12. National Institutes of Health Consensus Panel. NIH Consensus Development Conference Statement on total knee replacement

December 8-10, 2003. PMID: 17308549. Available online at:

https://consensus.nih.gov/2003/2003TotalKneeReplacement117html.htm Accessed November 2019.

13. Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD): Total Knee Arthroplasty (L36577). 2016.

https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=36577&ContrId=358&ver=9&ContrVer=1&CntrctrSelected=358*1&Cntrctr=358&s=56&DocType=

2%7c3%7c4%7c6&bc=AAgAAAQAAAAA& Accessed November 2019.

14. Dettori JR, Ecker E, Norvell D, et al. Total knee arthroplasty. Health Technology Asessment. Prepared for the Washington State

Health Care Authority by Spectrum Research, Inc. Olympia, WA: Washington State Health Care Authority; August 20, 2010.

15. Martin GM, Crowley M. Total knee arthroplasty. UpToDate Inc., Waltham, MA. Last updated September 2018

16. Nelson, AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of

osteoarthritis: The chronic osteoarthritis management of the U.S. bone and joint initiative. Semin Arthritis Rheum. 2014: 43

(6):701-12. PMID 24387819.

History

Date Comments 11/11/13 New Policy. Added to Surgery section. Considered medically necessary when criteria

are met. Approved with 90-day hold for provider notification; this policy is effective

February 15, 2014.

03/31/14 Coding update. ICD-9 Diagnosis codes 170.7, 170.8, 716.16, 996.43, and 996.44 added

to policy.

09/08/14 Annual Review. Policy rewritten with removal of reference to MCG guidelines; all

coverage criteria are now available within this policy; no change in coverage.

12/22/14 Interim update. Removed reference #1.

01/26/15 Update Related Policies. Add 7.01.144.

03/24/15 Update Related Policies. Change title to 7.01.549.

http://www.koos.nu/http://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/SMOAK%20CPG_4.22.2016.pdfhttp://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/SMOAK%20CPG_4.22.2016.pdfhttps://orthoinfo.aaos.org/en/treatment/total-knee-replacementhttps://consensus.nih.gov/2003/2003TotalKneeReplacement117html.htmhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36577&ContrId=358&ver=9&ContrVer=1&CntrctrSelected=358*1&Cntrctr=358&s=56&DocType=2%7c3%7c4%7c6&bc=AAgAAAQAAAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36577&ContrId=358&ver=9&ContrVer=1&CntrctrSelected=358*1&Cntrctr=358&s=56&DocType=2%7c3%7c4%7c6&bc=AAgAAAQAAAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36577&ContrId=358&ver=9&ContrVer=1&CntrctrSelected=358*1&Cntrctr=358&s=56&DocType=2%7c3%7c4%7c6&bc=AAgAAAQAAAAA&

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Date Comments 05/27/15 Annual Review. No change to policy statements. No references added.

02/09/16 Annual Review. No change to policy statements. No references added.

07/01/16 Interim Review, approved June 14, 2016. Removed Physical Therapy requirement of 6

visits over 12 weeks.

11/01/16 Interim Review, approved October 11, 2016. In osteoarthritis/degenerative joint

disease policy statement, clarified physical therapy statement from “if indicated” to

“unless not tolerated”. Retained link to KOOS site and removed KOOS information

from Appendix. Added Prior Authorization Requirements. Converted to new format.

Removed reference 3. Added reference 9.

01/24/17 Minor formatting update; added second level bullets in Prior-Authorization

Requirements section.

03/01/17 Annual Review, approved February 14, 2017. Policy section and Prior Authorization

requirements updated to clarify that a copy of the radiologist’s report must be

submitted for diagnostic imaging performed within the past 12 months and read by an

independent radiologist when submitted requests for treatment related to

osteoarthritis or degenerative joint disease. This replaces verbiage previously

indicating an x-ray report.

03/01/18 Annual Review, approved February 27, 2018. Clarified that the medical necessity

criteria are for total knee and unicompartmental arthroplasty. Revised policy statement

using descriptors of Kellgren Lawrence Grading Scale and Modified Outerbridge

Classification. Intent of policy unchanged. Clarification added that this policy does not

address patellofemoral knee arthroplasty. Reference added.

03/09/18 Minor update, added Documentation Requirements section.

04/01/19 Annual Review, approved March 12, 2019. References 11-16 added. Requirement that

a copy of the radiologist’s report must be submitted for diagnostic imaging performed

and read by an independent radiologist reinstated. Minor edits for clarity; otherwise

policy statements unchanged.

05/10/19 Minor update, removed requirement that imaging must be performed and read by an

independent radiologist, as this was inadvertently added back to policy.

12/01/19 Interim Review, approved November 21, 2019, effective March 5, 2020. Added

description of Kellgren-Lawrence grade 3 back to medical necessity statement of

radiographic evidence. Modified conservative management to include one or more

medical measures and physical measures unless symptoms are severe and there is

radiographic evidence of advanced osteoarthritis then only one or more medical

measure is required.

04/01/20 Delete policy, approved March 10, 2020. This policy will be deleted effective July 2,

2020, and replaced with InterQual criteria for dates of service on or after July 2, 2020.

06/01/20 Coding update. Removed CPT code 27445.

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Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The

Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and

local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review

and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit

booklet or contact a member service representative to determine coverage for a specific medical service or supply.

CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2020 Premera

All Rights Reserved.

Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when

determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to

the limits and conditions of the member benefit plan. Members and their providers should consult the member

benefit booklet or contact a customer service representative to determine whether there are any benefit limitations

applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

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(Arabic): ةالعربي a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a امةھ ماتولعم اراإلشع ھذا يحوي . أو طلبك وصخصب مةمھ اتمولعم عارشإلا ھذا ويحي قد

mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga اللخ من ھاعلي لوالحص تريد التي التغطية LifeWise Health Plan of Washington. قدawan ti bayadanyo. Tumawag iti numero nga 800-592-6804 (TTY: 800-842-5357).

على اظلحفل نةعيم يخراوت في إجراء التخاذ اجتحت قدو . اإلشعار ذاھ في مھمة يخراوت ھناك تكون ةدمساعوال تالوملمعا ھذه على ولحصال لك يحق .يفكالتال دفع في دةاعسملل أو يةحصلا تكطيتغ

فةلكت أية بدتك دون تكغلب (TTY: 800-842-5357) 6804-592-800بـصل ات .

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037336 (07-2016)

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https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@LifeWiseHealth.com

้

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Washington. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນ້ີ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າ ເນີ ນການຕາມກໍ ານົດເວລາສະເພາະເພື່ ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລ່ື ອງຄ່າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນ້ີ ແລະ ຄວາມ ວຍເຫຼື ອເປັ ນພາສາຂອງທ່ານໂດຍບໍ່ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-592-6804

(TTY: 800-842-5357).

ភាសាែខមរ (Khmer):

ມູ ຮັ ສິ

ມູ ຂໍ້

ສໍ

ຈ່

ວັ

ມູ ຂໍ້ ມີ ໝັ

ຊ່

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin LifeWise Health Plan of Washington. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-592-6804 (TTY: 800-842-5357).

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Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de LifeWise Health Plan of Washington. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de

េសចកតជី ូ នដំ ងេនះមានព័ ី

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់ តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ជូ ត៌ ណឹ នដ

រងរបស់អន

LifeWise Health Plan of Washington ។ របែហលជាមាន កាលបរ ិ ឆ ំ ់ េចទសខានេនៅ

មានយ៉ា ំ ់ ត ងសខាន។ េសចក ំណឹងេនះរបែហល

កតាមរយៈ

ងេសចកត ី នដណងេនះ។ អករបែហលជារតវការបេញញសមតភាព ដល់ ណត់ ំ ឹ ន ូ ច ថ កំ ជូ កន ុ determinadas fechas para mantener su cobertura médica o ayuda con los អន ៃថងជាកចបាសនានា េដ ី ឹ ុ ៉ ប់ ុខភាពរបស់ ក ឬរបាក់ costos. Usted tiene derecho a recibir esta información y ayuda en su idioma ់ ់ ើមបនងរកសាទកការធានារា រងស

ក sin costo alguno. Llame al 800-592-6804 (TTY: 800-842-5357). ជ ំ យេចញៃថ កមានសិ េដាយមិ ុ ើ ូ ូ នអសលយេឡយ។ សមទ

ទធ នួ ល។ អន នួ ិ ួលព័ ៌ ិងជំ ន ុងភាសារបស ទទ តមានេនះ ន យេនៅក អន ់

800-592-6804 (TTY: 800-842-5357)។

រស័

ਅੰ

ਜਾਬੀ (Punjabi): paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋ ਿਟਸ ਿਵਚ LifeWise Health Plan of tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng LifeWise

Health Plan of Washington. Maaaring may mga mahalagang petsa dito sa Washington ਵਲ ਤੁ ਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹਤਵਪੂ ੋ ਸਕਦੀ ਹਾਡੀ ਕਵਰੇ ੱ ਰਨ ਜਾਣਕਾਰੀ ਹ

ពទ

paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang ਹੈ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਂ ਹਨ. ਜੇ ੁ ੇ ੱ ਖਣੀ ਹੋ ੇ mga itinakdang panahon upang mapanatili ang iyong pagsakop sa . ਇਸ ਨ ਸਕਦੀਆ ਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰ ਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ੱ ੁ ੋ ਤਾਂ ਤੁ ੰ ੂ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ਇਛਕ ਹ ਹਾਨ ੱ ਝ ਖਾਸ

ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag ਕਦਮ ਚੁਕਣ ਦੀ ਲੜ ਹੋ ਸਕਦੀ ਹ ੈ,ਤੁ ੰ ੂ ਮੁ ੱ ਚ ਤੇ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ੱ ੋ ਹਾਨ ਫ਼ਤ ਿਵ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਮਦਦ sa 800-592-6804 (TTY: 800-842-5357). ਪ੍ਰ ੈਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-592-6804 (TTY: 800-842-5357).

ਪੰ

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang

ไทย (Thai): ประกาศน ้ีมีข้อมลูสําคญั ประกาศน ้ีอาจมีข้อมลูที่สําคญัเกี่ยวกบัการการสมคัรหรือขอบเขตประกนั

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين . ميباشد ھمم اطالعات یوحا يهمالعا اين

สขุภาพของคณุผ่าน LifeWise Health Plan of Washington และอาจมีกําหนดการในประกาศ طريق از ماش ای مهبي وششپ يا و تقاضا LifeWise Health Plan of Washington به .باشدี น جهتو يهمالعا اين در ھمم ھای خيتار يا تان بيمه وششپ حقظ برای است کنمم ماش . يدماين کمک คณุอาจจะต้องดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกนัสขุภาพของคณุ

اجتياح صیاخ کارھای امانج برای صیمشخ ھای خيتار به تان، انیمدر ھای زينهھ پرداخت درหรือการช่วยเหลือที่มีค่าใช้จ่าย คณุมีสิทธิที่จะได้รับข้อมลูและความช่วยเหลือน ้ีในภาษาของคณุโดยไม่ม ีباشيد داشته . رايگان ورط به ودخ انزب به را مکک و اطالعات اين که داريد را اين حق ماش

(ค่าใช้จ่าย โทร 800-592-6804 (TTY: 800-842-5357 مارهش با اطالعات سبک برای . نماييد دريافت 800-592-6804 . اييد نم برقرار استم ) 5357-842-800 مارهباش اس تم TTY کاربران(

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez LifeWise Health Plan of Washington. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-592-6804 (TTY: 800-842-5357).

Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do LifeWise Health Plan of Washington. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para 800-592-6804 (TTY: 800-842-5357).

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