DraftPremera BluecrossPolicy N/A

Shoulder Arthroplasty (Total, Reverse, Hemi-, and Revision) Coverage Criteria

Medical policy describing indications, documentation, and coding for total, reverse, hemi-, and revision shoulder arthroplasty for Premera Bluecross members and their providers.

Policy Summary

PayerPremera Bluecross

PolicyShoulder Arthroplasty (Total, Reverse, Hemi-, and Revision) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdded material coverage statementminor reorganizations

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document a history of disabling pain or functional limitation, at least 3 months of failed conservative management plus a 6-week trial of directed physical measures, and imaging within 12 months prior to authorization.

SourceLink

POLICY UPDATE CHANGES

Total shoulder arthroplasty, reverse total shoulder arthroplasty, and shoulder hemiarthroplasty may be considered medically necessary when criteria are met.

Some policy criteria reorganized for consistency; minor edits made to policy statements for clarity during interim review.

100,000+estimated annual number of shoulder replacement surgeries

3 monthsrequired duration of failed conservative management

6 weeksrequired trial of directed physical measures

90-dayprovider notification period

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.

108planned enrollment (trial)

Coverage Criteria for Shoulder Arthroplasty

Total shoulder arthroplasty - Initial criteria

Total shoulder arthroplasty may be considered medically necessary when ALL of the following are met:

Diagnosis: There is a documented diagnosis of one of: degenerative joint disease (DJD)/osteoarthritis (OA), rheumatoid arthritis (RA), traumatic arthritis, or avascular necrosis.

Clinical need: Treatment is needed because of disabling pain and/or functional disability interfering with activities of daily living (ADLs) for at least 3 months.>= 3 months

Imaging: Radiographic or imaging evidence of destructive degenerative joint disease of the shoulder within 12 months prior to surgery, evidenced by one or more of: irregular joint surfaces; glenoid sclerosis; glenoid osteophyte changes; flattened glenoid; cystic changes in the humeral head; joint space narrowing.imaging within 12 months

Conservative management: Documentation of three months of failed non-operative conservative management (anti-inflammatory medications or analgesics and/or intra-articular corticosteroid injection as appropriate) AND a 6-week trial of directed physical measures (physical therapy, activity modification, flexibility and strengthening exercises) under the direction of a healthcare professional.3 months + 6 weeks

Reverse total shoulder arthroplasty - Criteria

Reverse total shoulder arthroplasty may be considered medically necessary when ALL of the following are met (or for specific listed conditions):

Indications allowing reverse TSA: Indications allowing reverse total shoulder arthroplasty: proximal humerus fracture malunion/non-union; reconstruction after tumor resection of the glenohumeral joint or surrounding tissue; failed hemiarthroplasty; post-traumatic injury causing shoulder joint destruction; failed total shoulder arthroplasty with non-repairable rotator cuff tear.

Functional and anatomic prerequisites: intact deltoid muscle; at least 90 degrees of passive shoulder range of motion (elevation/flexion); adequate bone stock to support an implant.>= 90 degrees passive ROM

Conservative management: Prior trial of anti-inflammatory medications or analgesics, intra-articular corticosteroid injection as appropriate, and a 6-week trial of directed physical measures (physical therapy, activity modification, flexibility and strengthening exercises).6 weeks

Shoulder hemiarthroplasty - Criteria

Shoulder hemiarthroplasty may be considered medically necessary when ALL of the following are met:

Advanced joint disease or specific conditions: Advanced joint disease of the shoulder is present and at least ONE of the following: glenohumeral osteoarthritis with irreparable rotator cuff tear; glenoid bone stock inadequate to support a glenoid prosthesis; osteonecrosis of the humeral head without glenoid involvement; proximal humerus fracture not amenable to internal fixation; or tumor requiring reconstruction.

Conservative management: History of unsuccessful three-month trial of failed non-operative conservative management (anti-inflammatory medications or analgesics and/or intra-articular corticosteroid injection as appropriate) AND a 6-week trial of directed physical measures under the direction of a healthcare professional.

Revision shoulder arthroplasty - Criteria

Revision shoulder arthroplasty may be considered medically necessary when ANY of the following are present:

Revision indications: Aseptic loosening of one or more prosthetic components confirmed by imaging; bearing surface wear leading to symptomatic synovitis or local bone/soft tissue reaction; displaced periprosthetic fracture; component instability; fracture, mechanical failure, or recall of a prosthetic component; migration of the humeral head; periprosthetic infection; recurrent prosthetic dislocation; persistent shoulder pain unresponsive to non-operative care for 6 months.

Indications for Shoulder Arthroplasty

Covered when clinical indications for shoulder arthroplasty are met

Indications: Osteoarthritis (typically >55 years) with symptomatic cartilage loss causing pain and dysfunction; rheumatoid arthritis with chronic synovial inflammation causing cartilage damage; traumatic arthritis after major shoulder injury (fracture, dislocation, tendon/ligament tears) causing cartilage damage; avascular necrosis with bone death due to causes such as long-term steroid use, alcohol use, sickle cell disease, fracture, or radiation (commonly ages 30–50); severe or multiple proximal humeral fractures not reconstructable; tumor requiring resection and reconstruction; rotator cuff tear arthropathy or massive irreparable rotator cuff tears often treated with reverse shoulder replacement; failed prior shoulder replacement requiring revision for loosening, wear, periprosthetic fracture, infection, instability, or dislocation.

Descriptive list of covered indications.

Exclusions: Shoulder arthroplasty is not covered when any of the following exclusionary conditions are present: active infection of the joint or systemic bacteremia; active skin infection or open wound within the planned surgical site; deltoid deficiency (for example, axillary nerve palsy); inadequate bone stock to support implantation of a prosthesis; neuropathic (Charcot) arthropathy of the shoulder; paralytic shoulder disorder (e.g., flail shoulder due to irreversible brachial plexus palsy or spinal cord injury); rapidly progressive neurological disease; or allergy to implant components (e.g., cobalt, chromium, stainless steel, titanium).

Contextual evidence note: The National Institute for Health and Care Excellence (NICE) 2020 guideline for primary elective shoulder replacement recommends offering a total shoulder replacement when glenoid bone is adequate for treatment of osteoarthritis without a rotator cuff tear. The NICE committee was unable to make a recommendation regarding shoulder replacement for individuals with a prior proximal humeral fracture and persistent loss of function, reflecting limited or uncertain evidence for that specific indication.

Not medically necessary: Total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemi-arthroplasty are considered not medically necessary when the applicable medical necessity criteria in this policy are not met or when any of the exclusionary conditions listed above are present.

Scope limitation: This medical policy does not apply to Medicare Advantage members. Coverage for services is also subject to the specific limits and conditions of the member benefit plan; member contracts may impose benefit limitations that render a service not covered under a particular contract. Providers and members should consult the member benefit booklet or customer service to determine applicable coverage.

Coding and Related Requirements

Covered CPT CodesCPTCovered

23470	Arthroplasty, glenohumeral joint; hemiarthroplasty.
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g- 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.

Device product codesmixed

KWS	Device/product code listed in regulatory status
KWT	Device/product code listed in regulatory status
MBF	Device/product code listed in regulatory status
PAO	Device/product code listed in regulatory status
PHX	Device/product code listed in regulatory status
PKC	Device/product code listed in regulatory status
QHE	Device/product code listed in regulatory status

Conservative management duration

Required duration of failed non-operative managementDocumentation of three months (>= 3 months) of failed non-operative conservative management (anti-inflammatories/analgesics and/or intra‑articular corticosteroid injection as appropriate)

Directed physical measures trialA 6‑week trial of directed physical measures under supervision (physical therapy, flexibility and strengthening exercises, activity modification or reasonable restriction of activities)

Components of conservative careConservative management may include anti‑inflammatory medications, analgesics, and intra‑articular corticosteroid injection as appropriate

Imaging recency

Required imaging timeframeRadiographic or imaging evidence of destructive degenerative joint disease within 12 months prior to surgery

Provider Actions, Documentation & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for listed shoulder arthroplasty CPT codes. Providers must obtain authorization before scheduling services to avoid claim denials.

Prior authorization required for CPT codes: 23470, 23472, 23473, 23474.
Follow payer-specific prior authorization submission procedures and timelines.

Note

Prior Authorization / Medical Necessity

Procedures may be considered medically necessary when the policy’s clinical criteria are met. Providers should document how the patient satisfies the applicable medical necessity criteria prior to performing surgery.

Total shoulder, reverse total shoulder, and hemi-arthroplasty may be considered medically necessary when ALL required criteria are met.
Ensure prior authorization is obtained and medical necessity documentation is included with the request.

Background and Context

Background: Shoulder arthroplasty replaces damaged components of the glenohumeral joint with prosthetic implants to reduce pain and restore function when conservative management fails. Common procedure types include total shoulder arthroplasty (anatomic replacement of the humeral head and glenoid), reverse shoulder arthroplasty (implant configuration reversed with the ball on the scapula and the socket on the humerus, typically used when the rotator cuff is deficient but deltoid function is intact), and hemiarthroplasty (replacement of the humeral head only). These procedures are indicated for conditions such as osteoarthritis, rheumatoid arthritis, traumatic arthritis, avascular necrosis, complex fractures, tumor reconstruction, rotator cuff tear arthropathy, and failed prior arthroplasty.

Definitions

Total shoulder arthroplasty

DefinitionAnatomic replacement in which the humeral head is replaced with a ball component and the glenoid surface is replaced with a socket component.

PurposePerformed to remove damaged bone and cartilage of the glenohumeral joint and restore mobility and function.

Also known asAnatomic shoulder arthroplasty; total shoulder replacement.

Reverse shoulder arthroplasty

DefinitionImplant configuration reversed so the ball component is attached to the scapula (glenoid) and the socket component is attached to the humerus.

IndicationUsually performed when the rotator cuff is severely damaged or deficient and when deltoid function is intact.

Policy Summary

PayerPremera Bluecross

PolicyShoulder Arthroplasty (Total, Reverse, Hemi-, and Revision) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdded material coverage statementminor reorganizations

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Acceptable modalities/examplesX‑ray, CT, or MRI demonstrating findings such as irregular joint surfaces, glenoid sclerosis, osteophyte changes, flattened glenoid, cystic changes in the humeral head, or joint space narrowing

Documentation expectationImaging must be available in the medical record and dated within the 12‑month window prior to the planned procedure

Reverse TSA passive ROM

Passive ROM requirement for reverse TSAAt least 90 degrees of passive shoulder elevation/flexion documented prior to reverse total shoulder arthroplasty

Deltoid function prerequisiteAn intact deltoid muscle must be documented (required alongside passive ROM)

Bone stock considerationAdequate bone stock to support the implant must be documented

Documentation Required

Conservative Management Prerequisites

Conservative, non-operative management must be documented and exhausted prior to arthroplasty except for specific fracture/tumor indications that are not amenable to fixation.

Documentation of at least a 3-month trial of non-operative care (e.g., NSAIDs/analgesics and/or intra-articular corticosteroid injection as appropriate).
Documentation of a 6-week trial of supervised physical measures (e.g., physical therapy, flexibility and muscle strengthening exercises, or activity modification) under a healthcare professional’s direction.
Exceptions: acute fractures or tumor reconstructions where conservative care is not appropriate.

Step Therapy

Evidence Summary / Step Therapy Note

Evidence summarizes comparative outcomes between total shoulder arthroplasty and hemiarthroplasty and notes absence of explicit step-therapy requirements. Total shoulder arthroplasty generally shows better short- to mid-term pain relief and function versus hemiarthroplasty; long-term differences may be less clear. Reverse TSA demonstrates sustained improvement for massive irreparable rotator cuff tears. There is no policy-level step-therapy sequencing mandated beyond documented conservative care.

Total shoulder arthroplasty often provides superior short- to mid-term pain relief and function compared with hemiarthroplasty.
Long-term outcomes may show fewer statistically significant differences at extended follow-up.
Reverse total shoulder arthroplasty is supported for massive irreparable rotator cuff tears with durable functional improvement.
No formal step-therapy algorithm (beyond required conservative care) is imposed by this policy.

Documentation Required

Required Clinical Documentation

Required clinical documentation must be included with prior authorization and retained in the medical record. Incomplete documentation may delay or result in denial of authorization.

History of disabling pain and/or functional limitation interfering with activities of daily living.
Radiographic or advanced imaging evidence (see imaging documentation) demonstrating destructive degenerative joint disease or other indicated pathology within 12 months prior to surgery.
Documentation of at least a 3-month failed trial of non-operative conservative management and a 6-week trial of supervised physical measures, unless exception applies (e.g., unreconstructable fracture, tumor).
For revision/replacement: imaging-confirmed aseptic loosening, bearing surface wear with symptomatic reaction, displaced periprosthetic fracture, component instability, mechanical failure, migration, periprosthetic infection, recurrent dislocation, or persistent pain unresponsive to conservative care.
For reverse TSA: documentation of intact deltoid, >=90° passive shoulder elevation/flexion, and adequate bone stock to support an implant.

Documentation Required

Reverse TSA Specific Documentation

For reverse total shoulder arthroplasty specifically, document rotator cuff status and shoulder-specific functional measures that support the indication for reverse TSA.

Intact deltoid muscle on exam.
Passive shoulder range of motion with at least 90° of elevation/flexion.
Evidence of adequate bone stock to support implantation.
Indications examples: unreconstructable proximal humerus fracture, reconstruction after tumor resection, failed hemi-arthroplasty, failed total shoulder arthroplasty with non-repairable rotator cuff tear.

Documentation Required

Imaging Documentation

Imaging must support the diagnosis and surgical planning. Axillary and true AP radiographs are recommended; obtain advanced imaging when clinically indicated (CT or MRI).

Required radiographs: axillary and true AP views.
Advanced imaging (CT or MRI) at clinician discretion and when required to evaluate bone stock, component loosening, or soft tissue/rotator cuff integrity.
Imaging must be dated within 12 months prior to surgery and included with the authorization request when available.

Denial Risk

Triggers for Denial / Not Medically Necessary Conditions

The procedure is considered not medically necessary when policy criteria are not met or when exclusion conditions are present. Claims may be denied if these conditions exist.

Not medically necessary when ANY of the following are present: active joint infection or systemic bacteremia, active skin infection/open wound at the surgical site, deltoid deficiency (e.g., axillary nerve palsy), inadequate bone stock to support implantation, neuropathic (Charcot) arthropathy, paralytic shoulder disorders causing flail shoulder, rapidly progressive neurologic disease, or documented allergy to implant materials that precludes implantation.
If required conservative management or imaging evidence is lacking, the procedure may be denied as not medically necessary.

Note

Benefit Limitations / Contract Exclusions

Coverage is subject to member benefit plan limits, exclusions, and contract terms. Verify member eligibility and benefits prior to authorization. This policy does not apply to Medicare Advantage; consult the member’s benefit booklet or customer service for plan-specific limitations.

Coverage depends on the member’s benefit plan limits and exclusions; prior authorization approval does not guarantee payment if the service is excluded under the member’s contract.
Consult the member benefit booklet or contact customer service to confirm coverage and any applicable prior authorization or network requirements.

Alternate nameReverse total shoulder arthroplasty (reverse TSA).

Hemiarthroplasty

DefinitionPartial arthroplasty in which only the humeral head (ball component) is replaced and the glenoid is left intact.

Common indicationsProximal humerus fracture not amenable to internal fixation; tumor requiring reconstruction; situations with inadequate glenoid bone stock for a glenoid prosthesis.

GoalReduce pain and restore function while preserving the native glenoid surface when appropriate.

Rotator cuff tear arthropathy

DefinitionA condition that develops from a very large or irreparable rotator cuff tear leading to shoulder joint degeneration that often requires joint replacement.

Preferred treatmentOften best treated with reverse shoulder arthroplasty due to rotator cuff deficiency.

Clinical contextAssociated with pain, loss of function, and inability to repair the rotator cuff tendon complex.

Revision shoulder arthroplasty

DefinitionReplacement procedure performed after a failed previous shoulder replacement for reasons such as aseptic loosening, bearing surface wear, periprosthetic fracture, infection, instability, or recurrent dislocation.

Common revision indicationsAseptic loosening confirmed by imaging; bearing surface wear with symptomatic reaction; displaced periprosthetic fracture; component instability or mechanical failure; migration of the humeral head; periprosthetic infection; recurrent prosthetic dislocation.

DocumentationImaging confirmation of the failure mode and clinical records documenting persistent symptoms or complications leading to revision are expected.