Include all planned procedures in a single PA; each reviewed separately

When multiple diagnostic or therapeutic shoulder procedures are planned for the same operative session, include all relevant procedures in a single prior authorization (PA) request; each procedure requiring PA will be reviewed separately for medical necessity and may be partially approved. If additional procedures not fully approved in the PA are performed intraoperatively, submit clinical documentation with the claim showing intraoperative findings that support medical necessity; lack of supporting documentation may result in partial approval or claim denial.

• Include all planned procedures in one PA request.
• Each procedure in the request will be reviewed individually and may be partially approved.
• If additional procedures are done without prior approval, provide intraoperative documentation with the claim to support medical necessity.

Prior authorization required/expected for listed shoulder procedures

Prior authorization is required or expected for the shoulder procedures listed in this policy; the policy is limited to the CPT codes enumerated in the Codes section and applies to elective, non‑emergent cases. Submit PA for listed CPTs (e.g., 23410, 23412, 23420, 23430, 29806, 29807, 29822, 29823, 29824, 29825, 29827, 29828) as applicable.

PA recommended for unlisted codes; some procedures require additional site-of-service review

For services reported with unlisted or not‑explicitly listed codes, prior authorization is recommended to avoid post‑service denials; certain procedures now also require review under the Outpatient Surgical Site of Service policy per interim updates. Follow the payer website lists and applicable review requirements when submitting unlisted or newly added procedure codes.

• Unlisted codes for potentially covered services: PA recommended to avoid post‑service denials.
• Interim updates: some procedures require review per Outpatient Surgical Site of Service policy.

Failure of conservative care (commonly ≥12 weeks) required for most indications

Most procedural indications require documented failure of conservative management before approval — commonly at least 12 weeks — unless an exception applies (e.g., acute traumatic complete tear with debilitating pain and loss of function).

• Failure of conservative management typically required for >= 12 weeks for listed procedures.
• Exceptions noted in specific criteria (e.g., acute traumatic complete rotator cuff tear).

Trial of PT plus ≥1 other conservative modality expected prior to surgery

Conservative management must include physical therapy plus at least one additional modality (e.g., anti‑inflammatories, nerve membrane stabilizers/muscle relaxants, intra‑articular corticosteroid injection, or activity modification/rest) unless contraindicated; physical therapy should occur within 6 months of the planned procedure.

• Physical therapy: within 6 months prior to surgery, either ≥3 PT sessions or a supervised patient‑specific home program (unless exception documented).
• Plus at least one other strategy: medications, injections, or activity modification.

Reserved provider-action callout

Reserved for provider action callouts.

Submit complete clinical and imaging documentation to demonstrate medical necessity

Submit documentation that supports medical necessity with the PA or claim: indication for surgery; clinical documentation of the extent of impairment and response to conservative care (including PT notes, activity modification, medication use, and outcomes of any procedures); imaging performed within the past 12 months with documented interpretation (radiologist report required for advanced imaging); and any criteria‑specific lab values or reports.

• Indication for requested surgery and evaluation of functional impairments.
• Clinical documentation of conservative care and its outcomes (PT notes, medications, injections).
• Imaging: performed within past 12 months; x‑ray interpretation may be by surgeon; radiologist report required for CT/MRI/US/bone scan.
• Any criteria‑specific lab values or reports.

Document PT within 6 months (≥3 sessions or supervised home program) plus another conservative therapy

Document conservative management per the policy definition: evidence of physical therapy within 6 months (either ≥3 sessions with a PT or a supervised patient‑specific home program) unless PT is contraindicated and this is documented, plus at least one other conservative therapy modality.

• PT within 6 months: ≥3 sessions OR supervised home program; document exception if PT not possible.
• Plus at least one additional therapy (medications, injections, or activity modification).

Follow updated documentation expectations from interim updates

Interim updates added and clarified documentation expectations; follow the policy's documentation requirements and the payer website for non‑covered and prior authorization details when submitting requests. Two codes were also added in recent interim updates.

• Additional documentation requirements were added in interim updates — ensure updated documentation is provided.
• Check payer website lists for non‑covered and PA details.
• Recent interim updates added two codes to the policy.

Insufficient documentation or unsupported intraoperative procedures may be denied or adjusted

Procedures performed without documentation meeting medical necessity criteria, or intraoperative procedures not supported by PA documentation, may be partially or fully denied or adjusted; providers may need to submit intraoperative findings or request reconsideration if claims are denied.

• Lack of documentation supporting requested services can lead to partial approvals or denials.
• If additional intraoperative procedures are performed without PA approval, submit clinical documentation with the claim to support medical necessity or request reconsideration.

Claims for procedures not listed may be denied

This policy is limited to the procedures listed in the Codes table; claims for procedures not listed in the policy's limited procedure list may be subject to denial.

Unlisted codes for non‑covered services will be denied; PA recommended for potentially covered unlisted codes

If an unlisted code is submitted for services the policy deems non‑covered, the claim will be denied as not covered; to avoid post‑service denial, prior authorization is recommended for unlisted codes submitted for potentially covered services addressed in this policy.

• Unlisted codes for non‑covered services: will be denied as not covered.
• Unlisted codes for potentially covered services: prior authorization recommended to avoid post‑service denial.