MA Total Shoulder Arthroplasty (Preauthorization Required)
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Policy governs medical necessity review and preauthorization requirements for total shoulder arthroplasty procedures for members of Blue Cross Blue Shield - Nebraska.
No material clinical or coverage changes in this revision.
Coverage Criteria
These Medical Policies are intended to guide benefit administration for Blue Cross Blue Shield - Nebraska members and outline conditions under which services related to total shoulder arthroplasty will be reviewed. The policies do not themselves constitute authorization, certification, or a contract for benefits; benefit determination for a particular service is made according to the terms and conditions of the member's applicable benefit contract. Providers should follow any plan-specific preauthorization procedures when requesting coverage for total shoulder arthroplasty.
The policy references Current Procedural Terminology (CPT) codes for administrative and billing purposes. CPT is the copyright of the American Medical Association; use of CPT terminology in this policy is for reporting and preauthorization workflow and does not imply coverage outside the applicable benefit contract.
Provider Actions and Requirements
Preauthorization required for total shoulder arthroplasty
Total shoulder arthroplasty requires preauthorization from Blue Cross Blue Shield of Nebraska before scheduling or performing the procedure.
Use Medical Policy when requesting authorization
Follow plan-specific preauthorization procedures and the Medical Policy when submitting requests; the policy text and Medical Policy Committee guidance are used to determine scientific validity and administer benefits.
- Providers are responsible for providing medical advice and treatment; use the policy to support benefit administration.
- Policies are subject to change and should be checked for updates prior to submission.
CPT coding and administrative usage
The policy references CPT codes and CPT terminology; use current CPT coding when submitting preauthorization and follow BCBSN administrative procedures for submission.
- Current Procedural Terminology (CPT) is referenced and subject to AMA copyright.
- Ensure code-level accuracy on preauthorization requests per plan requirements.
Policy use does not equal authorization or guarantee of benefits
These Medical Policies do not constitute authorization, certification, or a contract for benefits; benefit coverage for a service is determined by the terms and conditions of the member's applicable benefit contract.
- Do not consider policy wording alone as authorization—submit required preauthorization per plan processes.
- Verify member benefits and plan terms to confirm coverage decisions.
Background and Evidence
The Medical Policy Committee reviewed scientific publications and evidence when developing this policy, including reviews of indications, outcomes, and complications for anatomic and reverse total shoulder arthroplasty. The Committee periodically reassesses new and existing technologies and evidence to inform policy updates.
Evidence considered by the Committee spans peer-reviewed literature across multiple years and addresses clinical outcomes, expected benefits, and potential complications of total shoulder arthroplasty procedures. This policy is intended to summarize that review to support medical necessity determinations and preauthorization decisions for anatomic and reverse total shoulder arthroplasty.
Definitions and Legal Notices
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