ModifiedKaiser PermanentePolicy N/A

Clinical Review Criteria — Shoulder Arthroplasty

Clinical review criteria governing medical necessity determinations for shoulder arthroplasty procedures for Kaiser Foundation Health Plan of Washington members (Medicare and Non‑Medicare), including eligibility criteria, optimization requirements, and required documentation for prior authorization.

Policy Summary

PayerKaiser Permanente

PolicyShoulder Arthroplasty (Clinical Review Criteria)

Policy CodePolicy N/A

Change TypeAdoption of KP National/MCG criteriamaterial updates

Effective Date08/01/2026

Next Review DateN/A

Key ActionObtain prior authorization and submit last 6 months of clinical notes to document failed conservative therapy before scheduling shoulder arthroplasty.

SourceLink

POLICY UPDATE CHANGES

MPC approved to adopt KP National policy for Shoulder Arthroplasty; effective 08/01/2026 (60-day notice required).

Removed the IP only list.

Adoption of hybrid MCG criteria KP-S-634 for Shoulder Arthroplasty and KP-S-633 for Shoulder Hemiarthroplasty.

49Referenced items

5Procedure codes

<40BMI threshold

<8.0HbA1c threshold

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Procedure Codes and Clinical Thresholds

Considered medically necessary when criteria metCPTCovered

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.

Regulatory citations (no procedure codes listed)mixed

No codes listed

inv-10: HbA1c — clinical threshold guidance

HbA1c thresholdPreferred HbA1c < 8.0; A1c > 8.0 is a relative contraindication — members with A1c above goal must demonstrate active medical management and reduction over 3–6 months or documented shared decision making for case‑by‑case review.

Optimization periodDocumented attempts to improve glycemic control over 3–6 months required when A1c > goal; show active involvement with medical management and measurable reduction.

Case‑by‑case reviewIf optimization unsuccessful but adequate efforts are documented, the case may be reviewed on a case‑by‑case basis by a medical director.

inv-11: BMI — clinical threshold guidance (relative contraindication >40)

BMI thresholdPreferred BMI < 40; BMI > 40 is a relative contraindication and requires documented optimization efforts (sustained weight loss over 3–6 months or participation in weight loss/exercise program with formal nutritional counseling).

Optimization evidenceDocumentation must show sustained weight loss over 3–6 months OR stagnant weights despite active participation in a weight loss/exercise program plus formal nutritional counseling.

If optimization failsIf optimization attempts are unsuccessful, surgeon and patient may proceed with documented shared decision making; cases with adequate efforts may be reviewed case‑by‑case by a medical director.

inv-12: None in these reference chunks — placeholder key/value

No threshold listedNo additional numeric clinical thresholds are present in these reference chunks.

Regulatory referencesThis window contains referenced CMS manuals and regulatory citations but does not add other numeric thresholds.

Use existing optimization rulesFollow the BMI and HbA1c optimization requirements already stated in the policy for clinical decision making.

Prior Authorization, Documentation & Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for the site of service for listed shoulder arthroplasty procedures; use MCG KP-S-634 Care Guideline for medical necessity determinations. Surgery may be performed inpatient or outpatient but prior authorization supports choosing the most appropriate, cost-effective site of service.

Prior authorization required for site of service for shoulder arthroplasty procedures
MCG KP-S-634 referenced for non-Medicare members; effective through 2026-08-01 for elective surgical procedure level-of-care review

Documentation Required

Required Documentation and Denial Risk

Send clinical documentation to support medical necessity when requesting the service. Failure to provide required documentation or to document trial of conservative therapy may lead to denial.

Required documentation: last 6 months of clinical notes from requesting provider and/or specialist

Clinical Background

Shoulder arthroplasty is a surgical procedure that replaces the humeral head and/or glenoid; procedure types addressed in this policy include anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, hemiarthroplasty, and revision shoulder arthroplasty. Reverse total shoulder arthroplasty uses a reversed ball-and-socket configuration and is commonly indicated for rotator cuff deficiency and related conditions. The policy applies to both inpatient and outpatient settings and identifies specific CPT codes for covered procedures including 23335, 23470, 23472, 23473, and 23474.

Key Definitions and Guidance

inv-22: Reverse total shoulder arthroplasty — definition and clinical context

DefinitionReverse total shoulder arthroplasty: configuration where the mechanical 'socket' is placed into the humeral head and the 'ball' is attached to the glenoid; used for rotator cuff deficiency and other specific indications.

IndicationsIndicated for massive rotator cuff tear, failed rotator cuff repair, rotator cuff deficient arthropathy, certain fractures with cuff deficiency, failed prior arthroplasty, and other listed conditions.

Clinical contextMay be performed inpatient or outpatient; prior authorization is required for site of service for listed shoulder arthroplasty procedures per the policy.

inv-23: Consensus and appropriateness guidance — references to consensus statements and validated algorithms informing appropriateness

Consensus guidance citedPolicy references consensus statements and validated rehabilitation algorithms (e.g., American Society of Shoulder and Elbow Therapists consensus on rehabilitation for anatomic total shoulder arthroplasty).

Documentation Required

Conservative Therapy Requirements

Conservative (nonoperative) therapy must be tried and failed and documented prior to arthroplasty unless clearly not appropriate. Required elements include an anti-inflammatory medication trial ≥3 weeks (NSAID or acetaminophen or intra-articular corticosteroid as appropriate) and a trial of physical therapy within the last 12 months. If conservative therapy is not appropriate, the medical record must document why (examples: rapid progression of radiographic severity, rapid/progressive flexion contracture, or medical/social factors precluding conservative treatment). Additionally, replacement is supported when there are 3 months of disabling pain and 3 months of functional disability in age-appropriate activities of daily living.

Anti-inflammatory medication ≥3 weeks (oral/topical NSAID or acetaminophen) or intra-articular corticosteroid as appropriate
Physical therapy trial within last 12 months OR documented reason why conservative therapy is not reasonable
Replacement criteria include ≥3 months disabling pain and ≥3 months functional disability
Osteonecrosis of the humeral head included as an indication