MEDICAL POLICY – 7.01.550 Knee Arthroplasty in Adults

Effective Date: Oct. 1, 2021 RELATED MEDICAL POLICIES: Last Revised: Sept. 2, 2021 7.01.15 Meniscal Allograft and Other Meniscal Implants Replaces: N/A 7.01.144 Patient-Specific Cutting Guides for Joint Arthroplasty 7.01.549 Knee Arthroscopy in Adults 7.01.568 Designated Centers of Excellence: Total Knee or Total Hip Replacement 7.01.573 Hip Arthroplasty in Adults

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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 and failed 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

Note: This policy only applies to those age 19 and over. This policy does not apply to patellofemoral knee arthroplasty

Indication Medical Necessity Osteoarthritis or Total knee and unicompartmental arthroplasty may be degenerative joint disease 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 (Kellgren-Lawrence grade 3 or 4) in the 12 months prior to surgery evidenced by either: o Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour OR o Large osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity of bone contour 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

Page | 2 of 10 ∞ Indication Medical Necessity OR • For Kellgren-Lawrence grade 4 findings, a trial of only 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 Replacement/revision of Knee arthroplasty may be considered medically necessary for a previous arthroplasty 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

Page | 3 of 10 ∞ Documentation Requirements 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: 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

Page | 4 of 10 ∞ 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).

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

Page | 5 of 10 ∞ • 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

Background

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 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

Page | 6 of 10 ∞ 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

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, Harris, I. Total Knee Arthroplasty. Available on-line. UpToDate, Hunter, D (Ed), UpToDate®, Waltham, MA, Last updated Feb 24, 2020.

2. American Academy of Orthopaedic Surgeons. Unicompartmental knee replacement, patient information. 2016, Available online at: http://orthoinfo.aaos.org/topic.cfm?topic=A00585 Accessed September 27, 2021.

Page | 7 of 10 ∞ 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 September 27, 2021.

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 September 27, 2021.

8. American Academy of Orthopaedic Surgeons. Surgical Management of Osteoarthritis of the Knee. Evidence-based clinical practice guideline September 4, 2015. Available online at: https://www.aaos.org/globalassets/quality-and-practice- resources/surgical-management-knee/smoak-cpg_4.22.2016.pdf Accessed September 27, 2021.

9. 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.

10. American Academy of Orthopaedic Surgeons. Total Knee Replacement, Last reviewed June 2020. Available online at: https://orthoinfo.aaos.org/en/treatment/total-knee-replacement Accessed September 27, 2021.

11. 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 September 27, 2021.

12. Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD): Total Knee Arthroplasty (L36575). Revised 12/1/2019. https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=36575&ver=17&Date=&DocID=L36575&bc=iAAAAAIAAAAA& Accessed September 27, 2021.

13. 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.

14. 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.

15. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015; 373(17):1597-1606. PMID: 26488691.

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.

Page | 8 of 10 ∞ Date Comments 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.

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

Page | 9 of 10 ∞ Date Comments 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.

11/01/20 Policy reinstated effective February 5, 2021, approved October 13, 2020. Policy updated with literature review. References updated. Minor reformatting to policy statements for clarity; otherwise policy statements unchanged.

10/01/21 Annual Review, approved September 2, 2021.Policy reviewed. References added. Policy statements unchanged.

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). ©2021 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.

Page | 10 of 10 ∞

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ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ። Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti Arabic): partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti) العربية salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti يحوي ھذا اإلشعار معلومات ھامة . قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti التغطية التي تريد الحصول عليھا من خالل Premera Blue Cross. قد تكون ھناك تواريخ مھمة .(bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357 في ھذا اإلشعار . وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة في دفع التكاليف . يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة . اتصل :(Italiano (Italian بـ(TTY: 800-842-5357) 800-722-1471 Questo avviso contiene informazioni importanti. Questo avviso può contenere 中文 (Chinese): informazioni importanti sulla tua domanda o copertura attraverso Premera 本通知有重要的訊息。 本通知可能有關於您透過 Premera Blue Cross 提交的 Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe 申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期 essere necessario un tuo intervento entro una scadenza determinata per 之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母 consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. 語得到本訊息和幫助。請撥電話 。 800-722-1471 (TTY: 800-842-5357) Chiama 800-722-1471 (TTY: 800-842-5357).

037338 (07-2016) 日本語 (Japanese): Română (Romanian): この通知には重要な情報が含まれています。この通知には、 Premera Blue Prezenta notificare conține informații importante. Această notificare Cross の申請または補償範囲に関する重要な情報が含まれている場合があ poate conține informații importante privind cererea sau acoperirea asigurării ります。この通知に記載されている可能性がある重要な日付をご確認くだ dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în aceast notificare. Este posibil s fie nevoie s ac iona i pân la anumite さい。健康保険や有料サポートを維持するには、特定の期日までに行動を ă ă ă ț ț ă termene limită pentru a vă menține acoperirea asigurării de sănătate sau 取らなければならない場合があります。ご希望の言語による情報とサポー asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話 informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 ください。 (TTY: 800-842-5357).

한국어 (Korean): Pусский (Russian): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 Настоящее уведомление содержит важную информацию. Это 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 уведомление может содержать важную информацию о вашем Premera Blue Cross. 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 заявлении или страховом покрытии через В настоящем уведомлении могут быть указаны ключевые даты. Вам, 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 возможно, потребуется принять меры к определенным предельным 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . срокам для сохранения страхового покрытия или помощи с расходами. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 Вы имеете право на бесплатное получение этой информации и 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 . помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357). ລາວ (Lao): Fa’asamoa (Samoan): ້ ້ ້ ້ ແຈ້ງການນີ ມີ ຂໍ ມູ ນສໍ າຄັ ນ. ແຈ້ງການນີ ອາດຈະມີ ຂໍ ມູ ນສໍ າຄັ ນກ່ ຽວກັບຄໍ າຮ້ອງສະ Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ໝັ ກ ຫືຼ ຄວາມຄຸ້ ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala ວັນທີ ສໍ າຄັ ນໃນແຈ້ງການນີ້ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົ ດ atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua ເວລາສະເພາະເພື່ ອຮັກສາຄວາມຄຸ້ ມຄອງປະກັນສຸ ຂະພາບ ຫືຼ ຄວາມຊ່ວຍເຫືຼ ອເລື່ ອງ atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le ້ ້ ຄ່ າໃຊ້ຈ່າຍຂອງທ່ານໄວ້ . ທ່ານມີ ສິ ດໄດ້ ຮັບຂໍ ມູ ນນີ ແລະ ຄວາມຊ່ວຍເຫືຼ ອເປັ ນພາສາ aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai ຂອງທ່ານໂດຍບໍ່ ເສຍຄ່ າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357). i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i 徶羶ែខមរ (Khmer): ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). េសចកតជី ូនដណំ ឹងេនះ掶នព័ត៌掶ន架៉ ងស޶នំ។ ់ េសចកតីជូនដំណឹងេនះរបែហល ᾶ掶នព័ត៌掶ន架៉ ងសំ޶ន់អពំ ីទរមង់ ែបបបទ ឬζរ殶៉ បរង់ របសអ់ នក㾶មរយៈ Español (Spanish): Premera Blue Cross ។ របែហលᾶ掶ន ζលបរ េចិ ឆទសំ޶ន់េ俅កន ុងេសចកតជី ូន Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a ដណំ ងេនះ។ឹ អនករបែហលᾶរតវζរបេញូ ច ញសមត徶ពថ ដលក់ ណតំៃថ ់ ងᾶកច厶់ ស់ través de Premera Blue Cross. Es posible que haya fechas clave en este 侶侶 េដើមបីនងរកឹ 羶ទកζរ䮶侶ុ 殶៉ បរង់ សខ徶ពរបសុ ់អនក ឬរ厶កជ់ ំនួយេចញៃថល។ aviso. Es posible que deba tomar alguna medida antes de determinadas អនក掶នសទិ ធទទិ ួលព័ត掶នេ៌ នះ និងជំនួយេ俅កន ុង徶羶របស់អនកេ⮶យមនអសិ fechas para mantener su cobertura médica o ayuda con los costos. Usted លយេឡុ ើយ។ សូ មទូរស័ពទ 800-722-1471 (TTY: 800-842-5357)។ tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

ਪ ੰ ਜਾਬੀ (Punjabi): Tagalog (Tagalog): ਇਸ ਨ ੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨ ੋ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ƒ ਤੁਹਾਡੀ Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon ਕਵਰਜੇ ਅਤ ੇ ਅਰਜੀ ਬਾਰ ੇ ਮਹ ੱ ਤਵਪਰਨੂ ਜਾਣਕਾਰੀ ਹ ੋ ਸਕਦੀ ਹ ੈ . ਇਸ ਨ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ . tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue ਹੋ ਸਕਦੀਆਂ ਹਨ ਜੇਕਰ ਤਸੀੁ ਜਸਹਤ ਕਵਰਜੇ ਿਰੱ ਖਣੀ ਹਵੋ ੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring ਇਛ ੱ ੁਕ ਹ ੋ ਤ拓 ਤਹਾਨ ੁ ੰ ੂ ਅ ੰ ਤਮ ਤਾਰੀਖ਼ ਤ ƒ ਪਿਹਲ拓 ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੱ ਕਣ ੁ ਦੀ ਲੋੜ ਹ ੋ ਸਕਦੀ ਹ ੈ ,ਤੁਹਾਨੰ ੂ mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang ਮਫ਼ਤੁ ਿਵੱ ਚ ਤ ੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤ ੇ ਮਦਦ ਪਾਪਤ㘰 ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na 800-722-1471 (TTY: 800-842-5357). walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 .(Farsi): (TTY: 800-842-5357) فارسی اين اعالميه حاوی اطالعات مھم ميباشد .اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم :(ไทย (Thai تقاضا و يا پ وشش بيمه ای شما از طريق Premera Blue Cross باشد . به تاريخ ھای مھم در ั ประกาศนมข้ี ี ้อมลส ู ําคญ ั ประกาศนอาจม ้ี ีข ้อมลท ู ่ีส ําคญเก ั ่ียวกบการการสม ัครหร ั ือขอบเขตประกน اين اعالميه توجه نماييد .شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه . สขภาพของคุณผ ุาน ่ Premera Blue Cross และอาจมีก ําหนดการในประกาศนี ้ คณอาจจะต ุ ้อง ھای درمانی تان، به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد شما حق اين را داريد که اين اطالعات و ک مک را به زبان خود به طور رايگان دريافت نماييد . برای کسب ี่ ดําเน ินการภายในกาหนดระยะเวลาท ํ ่ีแนนอนเพ ่ ่ือจะร ักษาการประกนส ัขภาพของค ุณหร ุ ือการช ่วยเหล ือท اطالعات با شماره 1471-722-800 (کاربران TTY تماس باشماره 5357-842-800) تماس มคี่้่าใชจาย คณม ุีิิ่ี้ัู้สทธทจะไดรบขอมลและความชวยเหล ่ ื้ีอนในภาษาของคณโดยไม ุ่มค ี่้่าใชจาย โทร برقرار نماييد . 800-722-1471 (TTY: 800-842-5357) Polskie (Polish): To og oszenie mo e zawiera wa ne informacje. To og oszenie mo e ł ż ć ż ł ż Український (Ukrainian): zawiera wa ne informacje odno nie Pa stwa wniosku lub zakresu ć ż ś ń Це повідомлення містить важливу інформацію. Це повідомлення świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na може містити важливу інформацію про Ваше звернення щодо kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie страхувального покриття через Premera Blue Cross. Зверніть увагу на przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub ключові дати, які можуть бути вказані у цьому повідомленні. Існує pomocy zwi zanej z kosztami. Macie Pa stwo prawo do bezp atnej ą ń ł імовірність того, що Вам треба буде здійснити певні кроки у конкретні informacji we własnym języku. Zadzwońcie pod 800-722-1471 кінцеві строки для того, щоб зберегти Ваше медичне страхування або (TTY: 800-842-5357). отримати фінансову допомогу. У Вас є право на отримання цієї

інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за Português (Portuguese): номером телефону 800-722-1471 (TTY: 800-842-5357). Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio Tiếng Việt (Vietnamese): do Premera Blue Cross. Poderão existir datas importantes neste aviso. Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông Talvez seja necessário que você tome providências dentro de tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua determinados prazos para manter sua cobertura de saúde ou ajuda de chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông custos. Você tem o direito de obter esta informação e ajuda em seu idioma báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357). để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).