Shoulder arthroplasty (total, reverse, hemiarthroplasty, and revisions)
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Clinical review criteria governing medical necessity determinations and prior authorization/site-of-service review for shoulder arthroplasty procedures for Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. Applies to Medicare and non‑Medicare members covered by these Kaiser Permanente entities.
Kaiser Permanente approved adoption of hybrid MCG criteria KP-S-634 (Shoulder Arthroplasty) and KP-S-633 (Shoulder Hemiarthroplasty) for Medicare and Non‑Medicare members.
Medical Necessity Criteria for Shoulder Arthroplasty
General statement
Shoulder arthroplasty procedures are considered medically necessary when the applicable MCG clinical guideline criteria are met:
Applicable guideline depending on procedure and membership
- For Medicare members: Kaiser Permanente will use its own Clinical Review Criteria 'Shoulder Arthroplasty' and 'Shoulder Hemiarthroplasty' for medical necessity determinations when CMS guidance is absent.
- For Non‑Medicare members: Review for elective surgical procedure level of care using MCG guideline KP-S-634 for Shoulder Arthroplasty.
- For Non‑Medicare members: Review for elective surgical procedure level of care using MCG guideline KP-S-633 for Shoulder Hemiarthroplasty.
Documentation required to support medical necessity
When requesting these services, submit the following to support medical necessity:
ALL of the following
- Last 6 months of clinical notes from requesting provider and/or specialist
Site-of-service prior authorization
Prior authorization is required for the site of service for listed surgical procedures to encourage cost‑effective settings:
ALL of the following
- Prior authorization required for site of service for shoulder arthroplasty procedures performed in outpatient/inpatient settings as outlined by plan operations.
Applicable Procedure Codes
| 23335 | Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder). |
| 23470 | Arthroplasty, glenohumeral joint; hemiarthroplasty. |
| 23472 | Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)). |
| 23473 | Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component. |
| 23474 | Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component. |
What Providers Must Do
Site-of-service prior authorization required
Prior authorization is required for the site of service for the listed shoulder arthroplasty surgical procedures to encourage use of the most safe, appropriate, cost‑effective site of service. Verify authorization requirements for specific codes and plan type using the Pre-authorization Code Check.
Clinical documentation submission
Submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity determinations.
Clinical and Operational Background
Shoulder arthroplasty replaces the ball-and-socket components of the glenohumeral joint and includes anatomic total shoulder (replacement of the humeral head and glenoid cup), reverse total shoulder (reversing the ball-and-socket orientation), hemiarthroplasty, and revision shoulder arthroplasty. Surgery may be performed in a variety of settings, including inpatient hospital or medical center, off‑campus outpatient hospital or medical center, or on‑campus outpatient settings. Because costs vary by site of service and to encourage use of the most safe, appropriate, and cost‑effective setting, prior authorization is required for the site of service for the listed shoulder arthroplasty procedures.
Defined Terms
Policy Changes
Kaiser Permanente approved adoption of hybrid MCG criteria KP-S-634 (Shoulder Arthroplasty) and KP-S-633 (Shoulder Hemiarthroplasty) for Medicare and Non‑Medicare members; requires 60-day notice and is effective 2024-11-01.
Medical Policy Committee reviewed and last revised the policy on 2024-06-04.
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