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Shoulder Arthroplasty - Medicare Advantage (Revised)
Act
by Aug 1, 2025
Effective date
Aug 1, 2025
Identified
Jun 24, 2026
Summary
Humana has updated their Medicare Advantage policy for shoulder arthroplasty procedures, establishing specific medical necessity criteria for total shoulder arthroplasty, reverse total shoulder arthroplasty, hemi-arthroplasty, and revision procedures. The policy requires documentation of conservative treatment failure, functional disability, and specific anatomical conditions before approval.
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What to do
by Aug 1, 2025 · 3 steps
01Billing team and providers must review all shoulder arthroplasty cases to ensure documentation meets new Humana Medicare Advantage criteria including: 6 weeks of conservative treatment failure, functional disability documentation, radiological reports showing joint degeneration, and absence of contraindications (infection, deltoid deficiency, etc.).
02Update pre-authorization checklists and EMR templates to capture required elements.
03Cases not meeting criteria will be denied.
Original notice
Shoulder Arthroplasty - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.