Prior authorization and required medical necessity documentation

Surgical codes for open shoulder procedures listed in the policy require documentation that the applicable medical necessity criteria are met and may require prior authorization per payer process; include the operative indication and supporting imaging/assessment when submitting for authorization.

• Document that the specific indication meets policy medical necessity criteria.
• Include supporting imaging, exam findings, and conservative management trials when requesting authorization.

Prior authorization required for listed CPTs

Prior authorization is required/associated with the listed CPT codes for open shoulder procedures (arthrotomy, synovectomy, claviculectomy, acromioplasty, open rotator cuff repairs, capsulorrhaphy, open AC treatments, and other listed open shoulder procedures).

• Obtain prior authorization per payer rules when billing the CPTs listed for open shoulder procedures.

CPT codes affected — obtain authorization when billing

The policy specifies the CPT codes that will apply when effective; providers should obtain authorization per payer rules when billing these codes and ensure the billed CPT matches the documented operative procedure.

• Key CPTs called out include (examples): 23105, 23106, 23120, 23130, 23410, 23412, 23420, 23450, 23455, 23460, 23462, 23465, 23466, 23550, 23552, 23660, 23670, 23680, 23929 (see policy for full list).
• Refer to the policy history for the final effective CPT list and removed codes.

Conservative care documentation required prior to many indications

Before approval for many indications (decompression/acromioplasty, full-thickness rotator cuff repair, distal clavicle resection, shoulder dislocation, synovectomy), documentation must show prior conservative treatment including medication trial(s) and physical measures as specified by the policy.

• Medication options cited: NSAIDs, acetaminophen, and where appropriate subacromial or intra-articular corticosteroid injection.
• Physical measures include PT and/or directed home exercise for the durations specified.

Document trial of conservative therapies (medication + PT)

Providers should document trials of first-line conservative therapies (NSAIDs, acetaminophen, and intra-articular or subacromial corticosteroid injection as appropriate) and PT/directed home exercise prior to open procedures when indicated.

• Record duration and response to each medication trial.
• Document PT/home exercise modality, frequency, and duration.

Conservative management step (medication trial + physical measures) required

Conservative management requires both a medication trial and failure and a trial and failure of physical measures for specified indications; this combined medication-plus-physical therapy step must be tried and failed prior to approval for those procedures.

• This dual requirement applies to decompression/acromioplasty, full-thickness rotator cuff repair, resection of distal clavicle, shoulder dislocation, and synovectomy.

Required documentation elements: symptoms, exam, and imaging/testing

Medical records must document that medical necessity criteria are met for the specific indication, including the patient's symptoms, relevant physical exam findings (positive orthopedic tests), and supporting imaging/testing consistent with the indication.

• Examples: X-ray preferred for AC separation; MRI when soft tissue assessment is needed; MRI findings for instability (Bankart, Hill-Sachs) for dislocation indications.
• Include operative indication, positive physical exam tests, and imaging reports when submitting records or authorization requests.

Synovectomy documentation — symptoms plus imaging/biopsy and qualifying diagnosis

For synovectomy, document the presence of qualifying symptoms (joint pain, locking, pain with ROM, limited ROM, crepitus, or joint effusion) and include imaging or biopsy demonstrating pathology consistent with synovitis or joint effusion.

• Also document a qualifying diagnosis (e.g., inflammatory arthritis, PVNS, hemochromatosis, hemophilia, Lyme synovitis, recurrent hemarthrosis, synovial chondromatosis).
• Document trials and failures of conservative care and PT/home exercise where required.

Document trials/failures of medication and physical measures and required testing

When conservative management is required, providers must document trials and failures of both medication and physical measures (including durations) and any additional testing required by the indication before claim approval or authorization.

• Typical durations: three months of conservative management overall and at least 6 weeks of PT/directed home exercise unless exceptions apply.
• Include imaging or other diagnostic testing results when required by the indication (e.g., x-ray, MRI, CT).

Risk of denial for indications not listed or criteria not met

Procedures for indications not listed in the policy or when the specific criteria are not met are considered not medically necessary and may be denied if submitted without supporting criteria.

• Do not submit claims for indications not listed in the policy without documented justification meeting policy criteria.

Denial risk for missing conservative management, PT trial, or required testing

Failure to document required conservative management (three months of failed non-operative conservative care including medication trials and a 6‑week PT/home exercise trial where required) or required additional testing may result in denial.

• Lack of documentation of three months of failed non-operative management or lack of a 6‑week PT/home exercise trial may trigger denial.
• Missing required imaging or biopsy evidence for synovectomy or instability-related testing (e.g., MRI showing labral/Hill‑Sachs lesions) may trigger denial.