Obtain prior authorization with imaging, symptom duration, and failed conservative care

Prior authorization is required to establish that imaging-confirmed pathology, documented duration of function‑limiting pain, and failed provider‑directed non‑surgical management criteria have been met for the requested shoulder arthroplasty procedure.

• Imaging must be conclusive (radiograph, MRI, or CT) showing the specified pathology (e.g., advanced destructive degenerative joint disease, Walch B2/B3/C glenoid, posterior humeral head subluxation >50%, or proximal humerus fracture not amenable to fixation).
• Document function‑limiting pain duration (typically ≥3 months for primary procedures; >6 months for unexplained pain in revision cases).
• Document failure of provider‑directed, non‑surgical management for the required duration (see related step‑therapy block).

Verify coverage and prior‑auth requirements for the member/product

Verify member coverage and any prior authorization requirements before scheduling — codes and services listed in the policy may not be covered for all products or in all circumstances.

• Code lists in the policy are not all‑inclusive; coverage or prior authorization may be required for specific CPT codes or devices.
• Policy notes (E/I, NMN) and code annotations do not guarantee coverage—confirm with the member’s contract and payer rules.

Determine product‑level coverage applicability

Confirm whether the member’s specific product (commercial, Medicaid, Medicare, Essential Plan, Child Health Plus, DSNP, etc.) covers the requested shoulder arthroplasty service; medical policy criteria apply only when the product covers the service.

• If the product does not cover the service, the medical policy criteria do not apply.
• If the product covers the service, apply the policy criteria and prior authorization rules as indicated.

Document failed provider‑directed non‑surgical management (3 months primary; >6 months for some revisions)

Document failure of provider‑directed non‑surgical management for at least three months for most primary arthroplasty indications; for revision arthroplasty, document unexplained function‑limiting pain unresponsive to non‑surgical care for greater than six months when applicable.

• Record treatments attempted (e.g., physical therapy, medications, injections) and dates/duration of therapy.
• Specify that conservative care was provider‑directed and document lack of adequate clinical improvement over the required timeframe.

Reference AAOS guidance for nonoperative management (no automatic step‑therapy mandate)

Follow AAOS guidance when documenting nonoperative management: physical therapy and conservative options are appropriate nonoperative treatments; the policy references AAOS guidance but does not impose an explicit step‑therapy mandate.

• Document that appropriate nonoperative options (e.g., physical therapy) were recommended and tried as clinically indicated.
• Do not assume AAOS guidance creates an automatic step‑therapy requirement—document the individualized course of nonoperative care.

Include conclusive imaging or advanced diagnostic study with the request

Obtain and include conclusive radiographic imaging or an advanced diagnostic study (e.g., MRI, CT) that documents the specific pathology required by the indication (e.g., advanced destructive degenerative joint disease, inadequate glenoid bone stock, AVN, proximal humerus fracture not amenable to fixation, Walch B2/B3/C glenoid, or posterior humeral head subluxation >50%).

• Ensure imaging correlates with the individual’s reported symptoms and physical exam findings.
• For glenoid retroversion use CT to confirm Walch B2, B3, or C classification; for posterior subluxation document >50% on imaging.

Confirm device FDA status and monitor recalls/notifications

Confirm that any shoulder implant or component used has appropriate FDA regulatory approval and monitor FDA communications and recalls for devices; be aware the FDA maintains a list of medical device recalls and early alerts.

• Document the device used (manufacturer and model) and ensure FDA approval status when applicable.
• Monitor FDA Medical Device Recalls and Early Alerts for relevant communications affecting implanted devices.

Apply policy criteria only when the product covers the service

Apply the policy only when the member’s product covers the service; if the product does not cover the service, the medical policy criteria do not apply.

• For commercial, Medicaid, Medicare, Essential Plan, Child Health Plus, and DSNP products, follow the product‑specific coverage guidance in the policy statement.
• When product coverage exists, policy criteria govern prior authorization and coverage determinations.

Avoid procedures when exclusion conditions are present — high denial risk

Do not submit claims for arthroplasty procedures when any of the exclusion conditions are present — procedures performed with active local or systemic infection, paralytic shoulder disorders, Charcot joint, or uncontrolled/unstable medical conditions are considered not medically necessary and may be denied.

• Examples of uncontrolled conditions include cardiac, pulmonary, liver, genitourinary, metabolic disease, hypertension, or abnormal serum electrolytes.
• Deltoid deficiency is an exclusion for reverse total shoulder arthroplasty.

Verify coding coverage — code list may be incomplete

Codes listed in the policy may not be covered in all circumstances; the code list may not be exhaustive and AMA/CMS code updates may occur more frequently than policy updates — verify coding and coverage before billing.

• Treat code annotations (E/I, NMN) as policy guidance but confirm current coding/coverage with payer systems.
• Expect that additional or updated CPT codes could affect coverage; check payer code tables.

Coverage depends on product terms and policy criteria

Coverage and prior authorization depend on the member’s product terms; verify contract‑level coverage because codes and services may not be covered for all products and benefits.

• If the product does not cover the service, medical policy criteria do not apply.
• If the product covers the service, apply the policy’s criteria and prior authorization requirements.