Clinical Review Criteria — Shoulder Arthroplasty
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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.
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.
Coverage and Medical Necessity Criteria
Procedure Codes and Clinical Thresholds
| 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. |
| No codes listed |
Prior Authorization, Documentation & Provider Responsibilities
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
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
- Failure to document conservative therapy (see conservative therapy requirements) may result in denial
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
Step Therapy
No step therapy instructions are provided in these reference excerpts; no step-therapy program is specified for shoulder arthroplasty in this document.
- No step therapy instructions present — informational
Regulatory Sources Cited
Regulatory sources informing coverage and claims review include CMS manuals and databases. References cited include the Centers for Medicare & Medicaid Services Medicare Benefit Policy Manual (Chapters 1, 6, 15), the Medicare Program Integrity Manual (Chapter 6, Section 6.5), and the Medicare Coverage Database.
- CMS Medicare Benefit Policy Manual Chapter 1, 6, and 15
- CMS Medicare Program Integrity Manual Chapter 6, Section 6.5
- Medicare Coverage Database
Authorization / Denial Criteria (Informational)
There are no explicit operational authorization or denial criteria presented in these reference excerpts beyond the medical necessity and documentation requirements above; use the criteria in this policy and referenced MCG guideline for final determinations.
- No explicit separate authorization/denial algorithm provided in these excerpts — rely on policy criteria and documentation standards
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
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