Medicare AdvantageCoverageHigh impact
Shoulder Arthroscopy - Medicare Advantage (New)
Humana·AL, GA, TN, NC, SC, VA, WV · Orthopedics, Sports Medicine·Medicare Advantage
Effective date
Jan 2, 2026
We identified it
Jun 24, 2026
Summary
New Medicare Advantage policy establishes coverage criteria for shoulder arthroscopy procedures, requiring 3 months of conservative treatment (12 months for adhesive capsulitis) before arthroscopic intervention is considered medically necessary. The policy defines specific documentation requirements and clinical indications for various shoulder arthroscopy procedures.
Action Required
Before January 2, 2026: Billing team must update prior authorization requirements for shoulder arthroscopy CPT codes 29805-29807, 29819-29828. Ensure documentation includes radiological reports and proof of 3 months conservative treatment (12 months for adhesive capsulitis) with at least two specified treatments. Update encounter forms to remind providers of documentation requirements. Claims without proper documentation and conservative treatment history will be denied.