Obtain prior authorization and support indication-specific necessity

Prior authorization is required per-indication when billed with the listed CPT codes; submit medical records that show the specific medical necessity criteria for the indicated procedure are met.

• Applies to CPT codes listed in the policy (see coding tables).
• Documentation must support the indication-specific criteria referenced in the policy.

Submit pre-authorization with conservative therapy and imaging

Pre-authorization is expected for listed open shoulder CPT codes when applicable; submit required documentation including conservative management and imaging/diagnosis supporting the surgical indication.

• Include documentation of failed conservative therapy and imaging (e.g., x-ray, MRI) per the indication.
• Use the policy's listed CPT codes when requesting pre-authorization.

Verify CPT list and obtain prior authorization

When the policy is in effect, prior authorization is required for the listed shoulder open procedure CPT codes; verify the final effective CPT list because some codes were removed in an interim review.

• Policy history documents code additions/removals — confirm current applicable CPT codes before submission.
• Codes removed during interim review (e.g., 20680, 20670, 23040, 23044, 23101, 23107, 23415, 23585, 23615, 23616, 23630) should not be relied on without verification.

Document ~3 months of failed conservative management

Document that approximately three months of failed non-operative conservative management (medication trial such as NSAIDs or acetaminophen and, when appropriate, corticosteroid injection) has been attempted where required prior to surgery.

• Conservative management is not required for acute traumatic complete rotator cuff tears.
• Record medications tried (NSAIDs, acetaminophen, corticosteroid injections as appropriate) and durations.

Use a conservative-first, stepwise treatment approach

Follow a conservative-first, stepwise approach for nonurgent cases starting with physical therapy, pharmacologic management, and activity modification before progressing to surgery.

• PT and/or directed home exercise for at least 6 weeks is expected as part of conservative measures when specified.
• Escalate to surgical consideration only after documented failure of indicated nonoperative care.

Document both medication and physical therapy failures before authorization

Where specified, require and document both a medication trial (and failure) and a trial of physical measures (and failure) prior to authorization for listed open procedures.

• Policy revisions operationalize dual requirement (medication + physical measures) for decompression/acromioplasty, full-thickness rotator cuff repair, distal clavicle resection, shoulder dislocation, and synovectomy.
• Document both components of conservative care and justification if an exception applies.

Include required documentation elements in the record

Medical records must document that the medical necessity criteria for the specific indication are met, including presenting symptoms, positive physical exam findings, imaging results, and trials of conservative management with durations.

• Include presenting symptoms and the specific positive orthopedic test(s) referenced for the indication (e.g., Hawkins-Kennedy, Drop arm, Cross-Body Adduction).
• Attach imaging reports (x-ray preferred for AC separation; MRI when soft-tissue assessment is needed) and note PT/home exercise trial duration (minimum 6 weeks where required).

Document 3 months of failed non-operative care and ≥6 weeks PT

Document three months of failed non-operative management (NSAIDs, acetaminophen, intra-articular corticosteroid when appropriate) and a trial of PT and/or directed home exercise for at least 6 weeks where required.

• Record dates, agents used, response to therapy, and PT/home exercise details and duration.
• Note exceptions such as acute traumatic complete tears where conservative management may not be required.

Provide synovectomy-specific documentation (symptoms + imaging/biopsy + diagnosis)

For shoulder arthrotomy for synovectomy, document presence of one or more listed symptoms (joint pain, locking, pain with ROM, limited ROM, crepitus, or effusion) and include imaging or biopsy demonstrating pathology consistent with the reported condition plus a listed diagnosis.

• Include the specific diagnosis from the enumerated list (e.g., inflammatory arthritis, PVNS, synovial chondromatosis, hemochromatosis, hemophilia, Lyme synovitis, recurrent hemarthrosis).
• Attach imaging or biopsy reports that corroborate synovitis or joint effusion.

Ensure medical record documents trials/failures and additional testing

Document trials and failures of specified conservative measures (both medication and physical therapy) and any additional testing results required per indication; these records should support the indication-specific criteria cited in the policy history.

• When additional diagnostic testing is required per indication (e.g., MRI for instability, imaging for impingement or AC arthritis), include results in the submission.
• Ensure documentation aligns with the policy's enumerated criteria for the chosen CPT code.

Avoid requesting procedures for indications not listed in the policy

All indications not listed in the policy or clinical situations not described above are considered not medically necessary and may be denied; confirm that the requested procedure matches one of the policy's covered indications.

• If the clinical scenario is not described in the policy, include clear rationale and supporting evidence if requesting an exception.
• Services for deleted indications in the policy history may not be covered.

Denial risk if conservative care not documented or insufficient

Lack of documentation of three months of failed conservative management or absence of a trial of PT/directed home exercise for at least 6 weeks where required may result in claim denial.

• Verify that medication trials, injections, and PT/home exercise durations are explicitly recorded.
• Include objective notes on response or failure to conservative measures.

Denial risk for missing synovectomy symptom or imaging/biopsy evidence

For synovectomy, absence of required symptom documentation or missing imaging/biopsy evidence of underlying pathology consistent with synovitis/effusion and lack of an enumerated diagnosis increases the risk of denial.

• Ensure one or more qualifying symptoms are documented and accompanied by imaging or biopsy confirming synovial disease.
• Include the specific diagnosis from the policy's accepted list to support medical necessity for CPT 23105/23106.

Denial risk for missing pre-procedural conservative and testing requirements

Failure to document required conservative management (both medication trial and physical measures) or to provide required additional testing where specified may lead to claim denial for certain indications.

• This dual conservative requirement was added in the policy revision and applies to multiple indications including acromioplasty, rotator cuff repair, distal clavicle resection, shoulder dislocation, and synovectomy.
• Confirm that the submission contains both medication trial records and PT/home exercise documentation, plus any indicated imaging or testing.